Misconceptions
My initial dive into the subject occurred while reading the book about international medicine giant Paul Farmer "Mountains Beyond Mountains" by Tracy Kidder. Farmer described Cuba, a communist state, as one of the best examples of public health and universal access to care. I was astonished! How could my idol in global medicine be talking so highly about a communist nation? Here is an excerpt from the book (emphasis added):
"'For me to admire Cuban medicine is a given,' Farmer said. It was a poor country, and made that way at least in part by the United States' long embargo, yet when the Soviet Union had dissolved and Cuba had lost both its patron and most of its foreign trade, the regime had listened to the warnings of its epidemiologists and had actually increased expenditures on public health. By American standards Cuban doctors lacked equipment, and even by Cuban standards they were poorly paid, but they were generally well-trained, and Cuba had more of them per capita than any other country in the world-more than twice as many as the United States. Everyone, it appeared, had access to their services, and to procedures like open heart surgery. Indeed, according to a study by WHO, Cuba had the world's most equitably distributed medicine. Moreover, Cuba seemed to have mostly abandoned its campaign to change the world by exporting troops. Now they were sending doctors instead, to dozens of poor countries. About five hundred Cuban doctors worked gratis in Haiti now-not very effectively, because they lacked equipment, but even as a gesture it meant a lot to Farmer.
One time he got in an argument about Cuba with some friends of his, fellow Harvard professors, who said that the Scandinavian countries offered the best examples of how to provide both excellent public health and political freedom. Farmer said they were talking about managing wealth. He was talking about managing poverty. Haiti was a bad example of how to do that. Cuba was a good one."
Because of my upbringing I had learned to demonize communism, but in this instance at least, it had beaten the United States. I'm not turning this in to a political argument, but simply stating that my pre-existing beliefs had been challenged. I accepted the challenge and reevaluated my beliefs. "Perhaps," I thought to myself, "universal access to healthcare is important enough to give up some of my other long-held beliefs about socialism, communism, and (choke) the democratic party." Experiences like this don't occur very frequently for me, so I'm extremely grateful when they do, to change my misconceptions.
"A prejudice, unlike a simple misconception, is actively resistant to all evidence that would unseat it." - Gordon W. Allport
Government Controlled Healthcare
There are examples to oppose universal healthcare, too. The fact that universal healthcare is almost synonymous with government controlled healthcare, for me, is the biggest issue and the one where I have the most personal experience. Just think about the VA Hospital system. I've asked dozens of primary care physicians about their least favorite aspect of their job: they almost universally say "Paperwork and other menial tasks that don't benefit the patient, required by insurance companies and the government." Almost every physician has two medical assistants(MA) or more. One to help with patient care and the other to take care of phone calls and insurance requirements. One physician reported $60,000 per year for the MA who does paperwork. The most demanding and cumbersome insurance companies are medicaid and medicare, and most other companies follow their lead.
The rules and regulations are a burden of time, money, and energy. What might be even more bothersome to providers, however, are the rules dictating patient care. In England, a 51 year-old woman who had lived with years of knee pain did not qualify for knee replacement under the National Health Service (NHS) because of her age (source). She had to pay for the "elective" procedure out of pocket at a private hospital. In 2012 NHS budget cuts meant 52,000 patients were denied elective surgeries (source). When the government controls healthcare access and quality wax and wane with political seasons.
Rules and regulations from government-run programs means that some providers and hospital systems will "opt-out" and become private or "cash-only." The 51 year-old mentioned above sought treatment at a private hospital in London, one that does not accept NHS payments. The Mayo Clinic in Rochester, MN which is widely regarded as one of the best hospitals in the world reported in early 2016 they would no longer be a provider for Iowa Medicaid. While living in Peru I saw the wide disparities between the private and national hospitals. As a current medical student I can also state that interest in cash-only or concierge practice is increasing. My classmates and I are keenly aware of the burdens associated with insurance and medicaid.
Wait Times
While living in London my wife met a thirteen year-old young girl who had spent her entire life waiting for surgery to fix a club foot deformity. Thirteen years! This is almost certainly an outlier, but it is not uncommon for patients in England to wait 6 months for knee replacement or other similar "elective" surgeries, or as noted above to be denied surgery altogether. The national health system in Peru has expanded care to some of the nation's poorest, but long wait times are still a burden(source).
Unfortunately, the system we currently have in the United States right now is even worse because our motivation is profit. It is relatively easy and fast to have an expensive elective procedure performed in the United States. Those procedures are very lucrative. On the other hand, there can often be long wait times for primary care visits. In fact, our system is so lopsided that specialists outnumber primary care providers. Only in a profit-driven system would this ever make sense. Perhaps waiting six months for knee replacement or hernia repair is okay if it means timely and appropriate primary and preventative care.
Poverty
The core of the 'healthcare as a human right' argument is that even the poorest, most destitute deserve proper healthcare. The fact that someone in the upper middle-class may have to pay out of pocket for certain elective services or wait longer than expected is almost irrelevant. A classmate of mine recently said, "What you see as a customer service, I see as a basic right. While your priorities rest on quality, I am bothered by people without access to a form of quality." My perspectives, somewhat erroneously, were based on "customer service," things like wait times and patient satisfaction. How important is that when there is a whole section of our population without any service at all?
Conclusion
I warned you at the outset I wouldn't provide an answer to this complex problem. In fact, I really haven't added anything to the conversation which hasn't already been addressed ad nauseam by others. What I have done (or tried to do) is explain how my past experiences, combined with new insights, have shaped my current perspective. I believe that basic healthcare is a right, but I also believe that everyone should have some "skin in the game." We create more problems than we solve when we allow people to demand services without any thought of the cost to the system and the community.
The healthcare system in the United States is overly complex. Navigating the system is extremely difficult and burdens those in poverty most. There are examples of universal access to care from around the globe but they each come with their own set of problems and drawbacks. I have yet to find a perfect system. None of these facts, however, negate our responsibility to provide basic care to everyone regardless of socioeconomic status. Having said that, I'm not sure I could work in a system run by the government. I'm optimistic we can find another solution without ignoring those in need.
