Dr. Vivian Lee on solving the “conundrum” of U.S. health care
Per federal reporting, U.S. health care spending reached a whopping $3.6 trillion in 2018. Despite the large price tag, we’re still lagging behind the rest of the world. Harvard Medical School senior lecturer Dr. Vivian Lee proposes health care solutions in her new book, The Long Fix. She told Wake-Up Call how America could move forward post-Covid-19 — and the steps we could take to increase health care access.
Wake-Up Call: How does the U.S. health care system compare to systems in other developed countries, in terms of accesses and service services?
Dr. Vivian Lee: The U.S. health care system is really a paradox because we outspend every other country in the world. We spend more than two and a half to three times as much on health care per person than our counterparts for example, in most of Europe and Canada, Australia, and Japan. And yet our health outcomes on average are worse than many of our peer nations. We have higher infant mortality. We have higher maternal mortality almost by any measure.
Unlike many, we don’t have health care for everyone. So we still have around 8.5 million people, a number increasing during the Covid-19 crisis, who are uninsured — and even more who are underinsured.
But on the other hand, at the highest end, we have some of the very, very best health care models in the world in terms of caring for people with complex conditions or providing just state of the art technologies and medications. That’s why it’s such a conundrum. It’s just not evenly distributed.
Could you take us through some of your proposed solutions to these problems?
Our biggest problem is that our underlying health care business model is completely backward. And what I mean by that, is our underlying system requires us to pay for an action. Some call it a fee-for-service model of health care. Doctors, for example, or hospitals, get paid for doing things to people, regardless of whether it makes us healthier. So we get paid every time you have an MRI or have an operation or get a procedure done, even if it doesn’t improve your health at all. And that’s been true for the past fifty to sixty years. As a result, our whole health care system is economically incentivized to do more things to people, to over-diagnose, to over-treat, instead of really focusing on better health.
And there are some really great solutions out there to this. For example, for seniors, there’s a program within Medicare, called Medicare advantage. And within that, there are many clinics all over the country paid in a completely different way. They’re paid to keep people healthy. Doctors are rewarded for keeping those seniors healthy and out of the hospital. And as a result, they practice completely differently. Instead of rushing patients through eight-minute visits, they spend 30 minutes to an hour with each patient. They have yoga Tai Chi classes to prevent falls because falls are a huge cost driver and force many seniors to become dependent
When you start changing the business model, you see that we can get better health outcomes for people. And it costs less. Because you’re preventing hospitalizations in the long run, so we’re saving money and getting better outcomes.
What do you think Covid-19 has exposed about the health care system?
The Covid-19 crisis has been like a giant stress test on our health care system. And we completely failed it, right? We’re really not doing particularly impressively right now, but there are some silver linings.
One of these is the technologies we have at our fingertips. And there are a lot of mental health concerns around this country right now. Luckily, there are really interesting and effective ways to manage stress, anxiety, and depression, or other psychiatric medical conditions virtually. And for example, for patients with underlying conditions like diabetes, continuous glucose monitors can transmit blood sugar data to diabetes patients via an app on their cell phone.
What needs to fundamentally change as the country regroups from the pandemic?
We have to change how we think about health care in this country. Instead of our government’s health care program being almost like a giant insurance company or a health benefits plan, it really needs to be almost more like a Department of Health and Readiness. We have to think like the military does, preparing our country for war.
They spend a lot of time investing and preparing for things in order to prevent them from happening. And in our health care right now, because of the economic model, we’re investing a lot in reactive care instead of proactive, preventative care and public health. And we need to realize that the fundamental economic model of how we deliver health care has to change, to actually reduce a lot of the waste, and use that money to invest in public health and in health care for everyone.
Millions have filed for unemployment in the past few months. And many have lost their insurance along with their jobs. What are the pros and cons of a universal health care system versus our current model, especially amid this crisis?
Universal health care is a very politically charged topic. As a physician and as a scientist, the data shows that people who have access to health care are healthier. It improves their quality of life and longevity.
There was a really interesting study that was started in 2000, way before the Affordable Care Act, when three states — New York, Maine, and Arizona — decided to expand Medicaid and offer more health insurance to people who previously did not have any health insurance. They studied these three states for 12 years and they showed significant improvements in the overall health of the population and reductions in mortality.
So I think the science is clear that universal health care would lead to a healthier population and one that lives longer and more satisfying lives. The question that people have is: Can we afford universal health care? Right now health care is already consuming almost a fifth of the U.S. economy. And we still have about 10 percent of the American population who are uninsured. So many people naturally question: How are we going to pay for that health care for all of those people who are insured? And to that, I come back to my first point. Many studies now have affirmed that about 25 to 30 percent of each health care dollar we spend right now is wasted because we are in this fee-for-service paying for action model.
It’s also wasted in a lot of administration and bureaucracy. There are many different sources of waste, but if we could just recover a fraction of that waste, we can more than cover the health insurance for everybody in this country. And I think now with rising unemployment, it’s really imperative that we think really hard about how to do that.
This interview has been edited and condensed.
This originally appeared on Medium.