I have practiced medicine for decades in different settings in a variety of places. I decided to learn more about healthcare policy to understand what could be done to improve things. The constant pressure to do more for every patient with fewer resources, in less time, makes no logical sense. It is fraudulent to expect this to be done because it is not humanly possible.
When I went looking for information, I was astonished at what I found.
I decided to go back to school in Colorado to add a Health Care Administration MBA to my MD degree. My goal was to learn about the health care system from a business perspective. I knew that it was a complicated subject. I thought enrolling in a formal course of study would help me learn faster than tackling such a complex subject on my own.
What I didn’t expect was that my courses would be taught using materials that are heavily biased in favor of a universal health care system run by government.
The required textbook in my ethics of health care course used a false dichotomy to introduce students to health care ethics. The book claimed that one either believes that healthcare is a privilege or a right. If it is a privilege, “medically needed care may be delayed or not received at all if someone is underinsured and the necessary care is unaffordable because of costs.”
When health care is a right, the book asserted that “everyone will be provided access to affordable health insurance coverage to obtain medically needed care, with subsidies available to people at the lower end of the socioeconomic pyramid.”
There was no mention of the fact that even though health care may or may not be a right in the U.S., billions of dollars of free care is provided by Medicaid, by Federally Qualified Health Clinics, by hospitals under the Emergency Medical Treatment and Labor Act, by pharmaceutical companies, by numerous state and municipal programs, and by charitable physicians, hospitals, philanthropies, and individuals.
There was little mention of the fact that in countries in which health care is considered a right, there are long waiting lists for common procedures like MRI scans, hip replacements, and cataract surgery. Nor was there any mention of the data showing that richer patients wait less within publicly-funded systems. As economist John Goodman put it, “whenever the poor and the non-poor compete for resources in health systems that ban rationing by price, the poor always lose out.”
The textbook even failed to give both sides of the debate over how to measure Medicare’s administrative costs. “Before the ACA,” the authors claim, “for every dollar spent on private health insurance, 30 to 40 cents went toward administration costs and investment return to shareholders. For Medicare, an estimated 97 cents of each dollar is put toward actual health care.
Students never learned that other reputable estimates put Medicare overhead at closer to 6 percent of claims even when the costs of tax collection were ignored, or that private insurer administrative costs were closer to 6-14 percent of total costs.
The textbook portrayed people critical of universal health care and the Affordable Care Act as those in favor of injustice, inequity, and unfairness, a bias that might have been acceptable had the professor counterbalanced it with other viewpoints from respected experts.
Unfortunately, the assigned readings outlining other points of view were not equal either in number or credibility. The online class discussions were simply posts responding to the readings. They could not be balanced. Since few other viewpoints were presented in the textbook or in the assigned readings, they failed to explore other viewpoints in any significant depth.
Overreliance on the textbook left students ignorant of important health care policy ethical problems. Are healthcare reforms that are so expensive they will not be sustainable for more than a decade really just, equitable, and fair? Is claiming cost reductions ethical when real costs have merely been shifted to different groups rather than being reduced? Is it fair to reward people for making informed, unhealthy choices? Is it just to support policies that ignore patient autonomy and desires? Is it wise to adopt policies that drive doctors out of the practice of medicine?
I do not know how to calculate Medicare overhead or evaluate the cost of waiting lists. I do know that it is important to learn that there are divergent analyses. I want to know the truth, and the truth is that there are different evidence-based viewpoints about healthcare policy that lead to very different conclusions. They are not being taught in my health care policy MBA program. This makes it impossible to have productive debates on sorting through the evidence with the goal of identifying reform proposals that might work best.
Cheryl Meyers-Saffold, MD is an internal medicine physician in Colorado.
