Surgeon General Muddled Insights on Health Reform

Former U.S. Surgeon General: We’re Not Ready as a Nation for Single-Payer Healthcare; High Medical Debt ‘Obliterating Our Country’s Future’, MedPage Today, June 4-5, 2024, by Jeremy Faust

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Question: People in the comments section of your article did say, “Well, wouldn’t Bernie Sanders’ approach be better? Wouldn’t single-payer be the way?” And I always answer this question by saying, “I don’t know. I know it works in other countries, but I’m not sure this country is set up for that.” What do you think about that?

Jerome Adams: “You also can’t go to a system where you’re giving universal access to healthcare and single-payer until you can agree upon what that actually means.

“A real example: you go to Canada or the U.K. right now, and you’ll have no shortage of people who will tell you that they’re waiting 6 to 8 months for their elective surgery [A]. In the United States, if you take someone who comes in to their doctor in pain or with a diagnosis and they get told that they’re going to have to wait 6 to 8 months for their elective surgery, they will lose their minds and they’ll be on the phone with their lawyer or their local news station right away.

“We have a different expectation for what universal access to healthcare and a single-payer system would look like here versus other countries. Until we’re ready to have a very mature and nuanced conversation about that and about the fact that we can do this, but if we do this it means that you’re not going to be able to get what you want when you want [B] just because that’s the cultural expectation here. I think there’s a lot of nuance here.

“So at the end of the day, to answer your question, I don’t think that we are quite ready as a nation to really go there even though it sounds good. But I also think that we don’t have to. Switzerland, for instance, has a system where they provide access to a certain level of care for everyone in the country [C]. If you want more, you can buy it off of the market.

“I think there are hybrid systems that we can and should be thinking about that are predicated on giving people a baseline level of care, guaranteed, that do work and still allow a free market to exist.” …

Question: [T]alking about the high-deductible healthcare plans. I want to take the devil’s advocate [position] here and say, isn’t that the point of a high deductible?

Adams: … This is about the fact that 66% of bankruptcies in the United States are driven by medical debt. So regardless of whether you feel like it’s a person’s fault or not, we have a broader societal issue when … bankruptcies are being driven by this kind of debt [D]. That’s number one.

Number two, as I mentioned earlier about the Affordable Care Act [ACA], we’re now in a place where almost 60% of people with employer-provided health insurance — the ‘good insurance’ — are forced onto high-deductible health plans [E]. It’s not that they made a choice, it’s that that was the only option that they were given, or the plans are priced such that that’s the only one where I can afford the premium to go on. So it’s not like people out there are making the choice that they want this high-deductible health plan, they’re being pushed in that direction.

The final point I’d make about the high-deductible health plan … the whole premise of the high-deductible health plan was also to include HSAs, where you contribute to these HSAs on a monthly basis so you’ve got something in the kitty in case you have an emergency. … But also we know that many people, particularly from marginalized communities like Black and Brown individuals and individuals from under-resourced communities, often are uneducated about their HSA or don’t contribute to their HSA [F].

So you have a system set up that’s dysfunctional because people aren’t educated and they aren’t contributing to it. Even when they do everything right — like I do, I max out my HSA — you still could get hit with a bill in January [G] as opposed to December. Mayo Clinic, in this instance, isn’t waiting until December to get their money. They want their money now. and so I’ve got to come up with it now.

… Nobody thinks that they’re going to need emergency medical care! Heck, I didn’t think that I was going to pass out at a medical meeting after a hike. …

No one’s talking about this on the campaign trail. [H] You don’t hear Biden or Trump talking about this on the campaign trail. You don’t hear people running for Congress talking about this on the campaign trail, but it is 66% of bankruptcies. It’s literally just obliterating our country’s future in terms of putting people in medical debt. …

Again, I raised this because I want people to really understand that this is hitting all of us and it is not sustainable.

[W]e highlight the need for increased transparency and pricing. [I] … we also need to look at state policies to help people avoid surprise medical bills, not just for out of network, but again, from January surprises and all sorts of different ways that people run into surprise medical bills. …

We need collaboration between providers, insurers, and healthcare systems, to really figure out how we unstick this broken system.

Then, we need to improve high-deductible health plans. I think that it’s still workable, [J] but my situation showed that high-deductible health plans are actually setting a lot of people up for medical bankruptcies and the burden of medical debt.

[ HJM comments keyed to bracketed letters ]

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Comment:

By Jim Kahn, M.D., M.P.H.

Dr. Adams engages in policy analysis by anecdote. This is hazardous; omitting relevant evidence leads to faulty conclusions. He thus dismisses single payer in cavalier fashion. Below is a point-by-point critique (with, I should note, quite a few points of agreement):

[A] “They’re waiting 6 to 8 months for elective surgery” in Canada and the UK. These numbers aren’t relevant to US single payer. For starters, the UK NHS is under assault by the Tories. More generally, the OECD record for elective surgery wait times is quite good, with medians of 4-7 weeks in the best-performing countries … and we’d be starting with higher spending and more surgeons than any of them. Of course, elective surgery isn’t urgent, by definition. On other measures of access, such as for primary care, the US lags far behind other OECD nations.

[B] “If we do [single payer] it means you’re not going to get what you want just because that’s the cultural expectation here.” Hmm. Is the US cultural expectation to skip or delay care for financial reasons? To experience 2-3 years’ lower lifespan? Today, while the best-insured may get the medical care they want right away, most have to wait or can’t get it at all.

[C] “Switzerland, for instance, has a system where they provide access to a certain level of care for everyone in the country.” That “certain level of care” is standard and comprehensive. Only 8.5% of spending is voluntary health insurance.

[D] “66% of bankruptcies in the United States are driven by medical debt.” Got that right!

[E] “about the Affordable Care Act, we’re now in a place where almost 60% of people with employer-provided health insurance — the ‘good insurance’ — are forced onto high-deductible health plans.” Yup – forced into high deductibles. Not a choice.

[F] “we know that many people, particularly from marginalized communities like Black and Brown individuals and individuals from under-resourced communities, often are uneducated about their HSA or don’t contribute to their HAS.” Right – likely can’t afford to contribute. HSAs are regressive, benefiting the healthy and wealthy. They worsen inequality.

[G] “you still could get hit with a bill in January.” Right again … several thousand dollars within the deductible, all at once, with no financial reserves.

[H] “No one’s talking about this (medical debt & bankruptcies) on the campaign trail.” True. Biden mentions lower prescription drug costs for seniors, which help a bit. Trump discusses ending the ACA. Some progressive Congressional candidates discuss single payer.

[I] “we also need to look at state policies to help people avoid surprise medical bills.” We’ve tried that, and federal policies too. It doesn’t work – too complex and gameable, and even if it did succeed it would leave unresolved 25 other major problems with our fragmented insurance.

[J] “we need to improve high-deductible health plans. I think that it’s still workable.” Not really. The problem with high deductibles is that they leave individuals & families financially vulnerable. Other wealthy nations don’t use high deductibles. With good reason – they impair access to care, impoverish people, punish the poor, and don’t control health care costs

Come on, Dr. Adams – endorse a real solution, one proven in dozens of other countries. It’s nice to hear from a former Surgeon General on problems with our insurance. How wonderful would it be for him to endorse the effective and enduring policy solution – single payer.