Yes, Mr. President. Health Care is Complicated. And Also Hard.


“Nobody knew that health care could be so complicated,” President Donald Trump told us a few weeks ago.  As the failure of the House Republican  bill shows: Healthcare is hard.

The American Healthcare Act failed to clear the House of Representatives despite catering to longstanding conservative demands: rid the ‘individual mandate’ (designed to force able-bodied people to pay insurance so it’s cheaper for sick people), subsidies to individuals, and revamping Medicaid into block grants to states.

Even with the claim it could be deficit-neutral, the act failed to win enough moderate or conservative Republicans.

While Obamacare stays, the progressive wing of the Democrat party still calls for a single-payer Medicare-for-all health care system.

They would offer a dual catharsis: the moral certitude of declaring health care as a right; and the beguiling simplicity that one only need expand an existing entitlement and simply include the 264 million Americans not currently covered.

But leave aside questions of practicality and which option balloons the national debt further (both actually would), no proposed alternative delivers a cure-all.

At the heart of the question is a basic reality: We spent $3.2 trillion in 2015 on health care — that’s nearly $1 of every $5 that this nation produces.

There are several drivers for these healthcare costs.  My experience as a surgeon collaborating and teaching in several countries puts in stark relief, however, that many of these costs are unique to the United States.

Examine just three of these drivers — investments in research (which I support), expectations of the medical experience, and the controversies over end-of-life care–and we quickly see that difficult choices ahead.

My international experiences confirm what the data shows — countries spending a fraction on health care deliver excellent care.

Australia, for example, spends 9% of its GDP on healthcare to the United States’ 18%, but deliver better quality outcomes for many cancers, heart disease, and stroke.  Japan performs similarly well.

But no other country spends nearly $500 billion, more than 50% of the global total, on science and medical research.

And U.S. research yields discoveries: gene therapy to cure recurrent cancer; brain to limb connections that will help a paraplegic walk; and drugs that will dissolve clots before one damages a brain or heart.

Likewise, with only 5% of the world’s population, the U.S. covers 42% of all pharmaceutical investment that enables drug discoveries for which the rest of the world pays pennies on our dollars.

No country comes close in discoveries that will save lives, nor shows the generosity of Americans in paying forward for the world to benefit.

Trump proposes to end this generosity by crushing the National Institutes of Health.  But businesses already invest more in research than the federal government. Even if the NIH is stripped, Americans will still subsidize the world unless there is a fundamental shift.

Behold the pie chart of the American healthcare expenditure. Note that $1 trillion was spent on hospital services.

Nearly a quarter of all Medicare payments went to hospitals directly.  And a quarter of that went into administrative costs — almost double those for Canada.

Academic hospitals spend billions to supplement research budgets and underwrite resident training. They are safety-nets for many without health insurance.

But competition for lucrative hospital payments from insurers also drive renovations in many competing hospitals: luxe cedar-paneled maternity suites complete with waiters serving delicacies; patient rooms that might feature 1500- thread count bedsheets, wall-sized flat screen televisions, mood lighting, and decadent bathrobes and slippers you can take home.

While children’s hospitals in most countries that I visit still feature wards filled with dozens of beds, those in the U.S. offer all-private rooms.  The standard today is built-in video game consoles and iPads in every room, rollout beds and fully stocked kitchenettes for the parents.

In contrast, Canada has a tiered medical system where a single-payer government insurance system covers a ward bed in a room with four other roommates, while in the same hospital, private insurance or cash payments afford a single room with a host of amenities.

In Mexico City, separate hospitals cover the privately-insured.  So while a patient with the government insurance, Seguro Popular, will receive excellent care, but stay in large wards and bide time on waiting lists at a public hospital, the fortunate few with private insurance will experience a parallel universe of in-suite luxury and care that exceeds the best in this country.

Concierge medicine and separate suites for those who choose to pay has arrived in the United States, but do Americans want to see this era of tiered health care systems?  Will they pay for healthcare-for-all and luxury-for-all?

Finally, Americans must get honest about end-of-life care.  Of  the $554 billion spent by Medicare to cover 55 million Americans, nearly a third, or $170 billion is spent on a patient’s last six months of life.

We have the right, today to demand all measures to extend our lives–no matter the cost–even when treatment is futile.  This demand fuels extended stays in intensive care units that can cost well over $10,000 per night, and billion dollar hospital investments in proton beam accelerators, for example.

A family of a 90-year-old man may demand a treatment for metastatic melanoma with the breakthrough drug ipilimumab, which, on average, extends life by less than three months, but at a cost of $158,252 per person.

A scenario where a consumer may demand any product, any service, no matter the cost, and no matter the futility of treatment, while remaining separated from the cost, is unique to the United States.

A system that allows health care providers to charge any amount without revealing price lists is equally untenable.

But even an early attempt to promote a rational discussion regarding end-of-life-care with a patient or family in Obamacare statutes, was met with the odious, and indignant accusation of “death panels” and “rationing” of care.

While politicians reduced the critical healthcare discussion to ideological fusillades launched across the aisle, few politicians demonstrate the courage to level with Americans.

The most affluent nation in the world should indeed have the highest quality healthcare delivered in hospitals, clinics and rehabilitation facilities that are the envy of the world.  But these costs are being passed down across generations, even while Americans are treated to discussions that never focus on where their healthcare dollar actually goes.

This is what makes healthcare complicated.

Aseem R. Shukla, M.D., FAAP, is an Associate Professor of Surgery at the Perelman School of Medicine, University of Pennsylvania.  He writes at the intersection of healthcare, religion, and policy and tweets at @aseemrshukla “Views expressed here are personal”

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3 replies »

  1. One might assess our nation’s healthcare industry as suffering from an intransigent Paradigm Paralysis that has occurred as a result of a pervasive codependent relationship between the institutions that provide Complex Healthcare and the institutions that pay for this healthcare. As a result, both are unable to pursue there own ‘autonomy’ to act in the best interests of each citizen and their nation’s economy. If a person views all of this as very complex, it is. And the governance of these institutions are paralyzed by it. There is no reason to believe that any of the current “conversation” about healthcare reform will accomplish anything. But only if…

  2. Nice piece. There are so many things that make US health care more expensive. Your point about health care in other countries is good. When we travel we check out health care facilities. You virtually never see what you see in our local area. The surgicenters and short stay hospitals being built here have tons of flats screens, fountains, Olympic sized pools, 24 hour gourmet chefs available, etc. You usually see pretty basic facilities in other countries, just giving good care.

    I think you miss, or don’t emphasize an important point, which is tradeoffs. Not many people in health care, especially the policy makers and politicians, acknowledge that we need to make tradeoffs to achieve goals. To many promises of having everything. Too much advocating for plans that have never been shown to work.

    (What is it with you Penn guys blogging so much? When I was there we wouldn’t have time for this!)


  3. There is a doc at UCSF who speaks on this frequently at Grand Rounds, etc. She speaks the same message as you, Aseem: “All the OECD countries are doing essentially the same medicine and have approximately the same results, but the US prices and wages are singular and much higher.”

    I guess our utility function for health care in the United States is to feed 18% of the population. The health care system is our purpose, not health care per se. It is our hobby. It is our sport. Taking care of patients in an efficient way is not our primary purpose for this sector of the economy; feeding ourselves and having fun in the system are the essence.