Healthcare in America is in a deep crisis with few viable options

October 18th, 2023 by Tom Lynch

As Gaza burns and Israel wreaks mighty vengeance on the terrorists of Hamas (as well as innocent Palestinians), America is beset with its own set of domestic calamities, which, in any other era might be appreciated for the looming catastrophes they are, but now get the banal, desensitized response, “Oh, another crisis?”

As I write this, Republicans in the House of Representatives are hurtling down their own moronic, no-bottom rabbit hole, looking to do all in their power to make the U.S. Congress an even bigger global laughing-stock than it already is. These folks are like a dog with four back feet, each wanting to go in a different direction.

Ex-Ohio State University assistant wrestling coach and alleged sexual-abuse-enabler Jim Jordan is a little more than a heartbeat away from becoming Speaker of the House, second in line to the presidency. “Do you really want a guy in that job who chose not to stand up for his guys?” said former OSU wrestler Mike Schyck, one of the hundreds of former athletes and students who say they were sexually abused by school doctor Richard Strauss and have sued the university. “Is that the kind of character trait you want for a House speaker?”

Jordan says he never knew anything about it. His players say he’s lying. America yawns.

Meanwhile, over in the health care sector, Rome is burning.

Despite a steady drop in life expectancy over the last few years, the U.S. continues to spend nearly twice as much on health care as the average for the rest of the world’s developed countries. Consider this chart as backdrop for everything else that follows:

In the mid-1990s, I was a Trustee at a major teaching hospital in Massachusetts, a state with some of the best healthcare in the world. But there was a problem, and we all knew it. We were facing a shortage of primary care doctors, even as the nation’s healthcare intelligentsia had recently realized the importance of the field and were engaged in a solid effort to grow it. It was a noble effort, but while the industry established the Primary Care doctor as the gatekeeper and patient health strategist, it eventually came to treat that same Primary Care doctor as healthcare’s bastard stepchild. Too many patients, too many insurance requirements, too little time, all for too little money. Those chickens have come home to roost.

More than 145,000 healthcare practitioners, about half of them physicians, left the industry in the two-year period from 2021 through 2022, threatening access and quality, according to a report published Monday by Definitive Healthcare, a healthcare intelligence company.

Sixteen thousand of the health care providers who left were Primary Care doctors, 11,000 were psychologists or psychiatrists. About 9% of all healthcare workers who left the industry were licensed clinical social workers. Of the physicians and mental health practitioners who remain in the healthcare field, the average age is nearly 60. “Staffing shortages will deepen over the next few years,” said John Markloff, Definitive Healthcare’s senior director of data strategy.

And Primary Care shortages are more acute in rural areas than urban. The Health Resources and Services Administration has designated 7,200 regions across the country as Health Professional Shortage Areas, nearly all of them rural. “Generally, people who live in rural America are sicker, older, and come from a lower socioeconomic level,” says David Schmitz, MD, chair of the Department of Family and Community Medicine at the University of North Dakota and past president of the National Rural Health Association. “They are less well insured and tend to suffer from a lot of chronic diseases. And, by nature of where they are, it’s often difficult for them to access healthcare, even basic primary care.”

And Behavioral Healthcare suffers from the same shortages. Half of U.S. counties do not have a clinical psychologist, a psychiatrist or an addiction medicine specialist, which disproportionately affects low-income patients, according to data from George Washington University.

Why these shortages? Well, we could start with money.

According to the Medical Group Management Association, the median income of specialists is nearly twice that of primary-care physicians. The Group reported median income in 2021 for Specialists in the U.S. was $384,000, as opposed to $212,000 for Primary Care physicians.  To put even a finer point on it, the highest-paid gastroenterologists make about $846,000 a year; the highest-paid internists about $352,000 (in large urban areas). Think about that the next time you prep for a colonoscopy.

Moreover, the very factors that tend to make rural patients sicker are also those that make it difficult to recruit and retain healthcare providers for those areas, says Amitabh Chandra, director of health policy research at Harvard University’s John F. Kennedy School of Government.

“There are likely a lack of jobs in many of these places, as well as lower quality schools and housing,” he says. “Doctors know better than anyone the importance of good healthcare to a thriving community. Will they be comfortable moving to an area, and raising a family, in a place where you can’t get great hospital care — or perhaps any hospital care at all within a hundred miles?”

And here’s another shortage problem. More than 2,500 OB-GYNs and 2,800 anesthesiologists departed the healthcare field in 2022, according to the Definitive Healthcare study. Rural hospitals are struggling to maintain maternity wards as waning volume craters revenue, making it harder for these hospitals to continue caring for pregnant patients. This means maternity patients, like everyone else in most rural areas seeking care, must travel longer distances for it, which often leads to poorer outcomes. As I have written before, the U.S. has the highest rate of maternal mortality among developed nations.

Like so many things, all of this makes no sense at all.

So, what can be done?

Healthcare is so upside down in the U.S., nibbling around the edges won’t help. Although what we really need is a Marshall Plan for healthcare, which would cost a lot of money, I fear edge-nibbling is about all we can do — if we’re lucky.

After all, consider what it took, after over a decade of trying, to get Congress, through the Inflation Reduction Act, to allow Medicare to negotiate the price of a measly ten drugs for 2026. And that new-found ability to control costs may disappear if pharmaceutical companies and the Chamber of Commerce win lawsuits they have brought.

Consider all the effort Republicans put into their year-after-year attempts to repeal the Affordable Care Act (ACA), effort that could have gone into so much more productive work.

Consider Republican governors’ ferocious resistance to expanding Medicaid in their states through the ACA to get health care to the people who need it the most, but cannot afford it. After nine years, ten states still refuse to take the money the ACA offered.

Consider the ridiculous fact that, despite 91 charges in four criminal indictments, Donald Trump will be the likely nominee of the Republican Party for President next year. What would a second Trump term do to (not for) American health care, given the brick-throwing destruction of his first term. His first Executive Order, signed within hours of taking office, aimed at repealing the Affordable Care Act.

And consider that today, 18 October 2023, Jim Jordan may be elected Speaker of the United States House of Representatives.

In our polarized, sclerotic, even paralyzed, society none of this makes any sense. But here we are.