ADCOM Q&A: Problems in U.S. Health Care

It is undeniable that we in the United States have access to all kinds of health care procedures, medications, and specialists that, in many other countries, are only a pipe dream. Well, some of us. One of the responsibilities of the future generation of physicians - and politicians - is to help shape a better landscape for health care in which all Americans have access to these resources. That, of course, is easier said than done. But recognizing the problem is the first step toward a solution, so it makes sense that admissions committee members would ask a medical school interviewee something like this: What are three of the greatest challenges facing health care in the United States today?

First of all, that's not an easy question. I don't think anyone would argue that our system is systemically broken. So there are quite a few "challenges" I could talk about. But I will talk about three that dovetail into each other. That is, they are all related to money. Of course, pouring money into a broken system is not the solution in and of itself. But there are three money-related issues in health care that I want to talk about here. I don't have answers, perhaps only more questions. But asking those questions has gotten me researching these topics and learning more about the difficulties facing our health care system, and at least thinking about some possibilities for the future.

So here we go.

1. The lack of comprehensive health insurance for all Americans.

When I want to go to the doctor, I have to pay a small copay, sure. But the bulk of the charge gets paid by my insurance company. For an annual check-up, doing without insurance might not be such a big deal. But what if you have a chronic health problem such as diabetes, or wind up in the hospital for a week or two? You're looking at some hefty medical bills, medical bills that many, if not most, Americans couldn't pay out of pocket. So how big of a problem is this? Well, according to the most recent Census Bureau report, the number of uninsured Americans topped 50 million in 2010. That's 1 in 6 people in the country. Obama's health reform bill is supposed to help with this, but there is much controversy (and litigation) surrounding that bill. So while the number may have dropped some, it is still high. Too high. And that makes good health care - any health care - unaffordable to too many people.

2. The rising cost of prescription drugs. 

Prescription drug costs have increased wildly over the last few years. If you have decent insurance and are taking a round of antibiotics for a mild infection, this is not much of a concern. And there are some drugs available at Target and Wal-Mart for less than $5. But there are a couple of big problems facing people today. One is for those lacking insurance all together (see issue 1 above). For those people, drugs can cost, tens, hundreds, even thousands of dollars, depending on the medication. Clearly, that can make some drugs unaffordable all together. For people who have insurance, the rising cost of prescription drugs is still a concern, even though you might only be paying a fraction of the actual drug cost. Insurance companies are charging more for drug copays, especially for newer, brand-name, "fourth-tier" drugs. If say, you have diabetes, and you're on several of these pricier drugs (and a fixed income), that adds up to a lot of money, even with insurance. So why have these costs gone up? Well, for one thing, pharmaceutical companies charge a lot for their drugs. According to a study published on Kaiser.edu (a Web site associated with the non-partisan Kaiser Family Foundation), pharmaceutical manufacturing was the third most profitable industry in the country in 2008 (it was first between 1995 and 2002). Many argue that these high prices are necessary to encourage more research and development of new drugs, though ... so there's a dilemma there. Retail prescription prices have also outpaced inflation between 2000 and 2009, according to the same Kaiser Web site. Another issue is that most of the top-selling prescriptions are those newer, higher-priced drugs. And while hospital and other professional services have increased in cost, the growth rate for prescription drug costs is projected to overtake other categories of services between 2010 and 2019 (again, via Kaiser.edu). You've probably heard stories on the news of people having to decide between buying medicine and food. While these situations may not affect someone you know personally, they do happen. And that's not right.

3. The shortage of primary care physicians.

In the town where my mom grew up (the sleepy, 1,500-person town of Caldwell, Kansas), there was a town dentist - her father - and a town doctor. Everyone in town knew these two practitioners, because everyone in town went to them for their body aches and toothaches. These days, though, it's becoming less and less common for those little towns to have a resident physician, or even one anywhere nearby. This also applies to many urban and low-income areas. In fact, Kaiser.edu estimates that 60 million Americans (that's 1 in 5, folks) lack "adequate access to primary care due to a shortage of primary care physicians in their communities." So what's the problem? Again, in part: money. There is a huge income gap between a family physician or internist (we're talking well under $200,000, says Kaiser) and the mugh higher-paid specialists (try around $400,000 for radiology or cardiology). With the cost of medical school debt sometimes rising to $200,000 or $300,000, that higher salary looks appealing in terms of loan payoff, not to mention lifestyle considerations. Fewer medical school graduates are going into primary care, in part because of these financial issues. Which stem from our payment system. You get big bucks for procedures, pennies for an office visit. And all those phone calls that your family doc makes? He or she doesn't make a dime for that time. 

Our health care system here in the United States is, in some ways, the best in the world. People come from all over to see specialists at places like the Mayo clinic, for example. But the system doesn't work for everyone. We need to figure out a way to resolve that.