Accusations are common against doctors and other health professionals regarding their behavior and/or education: they cannot communicate, are misogynistic, racist and ageist, and are poorly educated, although American doctors have more training than those of other developed countries. But are these plaintiffs targeting the most obvious target, but not the most important? There are more pressing issues than patient-provider relationships, serious as they are, more serious concerns that have the potential to destroy an already fractured health care system. It won't do any good if we have doctors who are excellent communicators, but who don't have a functional health system within which they can function.
A few years ago, the Republican governor of a Southern state commissioned a study to determine the cost of Medicaid expansion to the state. Researchers determined that the program would generate millions of dollars for the state, a conclusion later confirmed by its implementation in other states. However, this was contrary to the governor's policy, and although lives, mostly black, would have been improved or saved, the report (although leaked) was never released and the program was not implemented. never been implemented. The state also has appalling maternal and child health statistics, particularly in rural and black areas. Having predominantly black and female providers offering rural prenatal clinics and birth centers to serve these women would likely have improved morbidity and mortality. In response, the state health department enacted regulations regarding a clinic's proximity to a Level III hospital for “patient safety,” although many women had never resided in that facility. neighborhood before the proposal, and despite this, accessible care would reduce the probability of complications requiring this proximity! If the agency was truly concerned about patient safety and the current disastrous results, why is it establishing an obstruction rule now? It is more likely that because the people to be served are people of color, the expanded Medicaid rule and limits are both racially motivated.
Additionally, public interest groups can be misguided in their attempts to help those they serve. In two cases, these organizations pressured the Food and Drug Administration (FDA) to make decisions based on “hope” and not evidence. Two amyotrophic lateral sclerosis patient organizations lobbied the FDA to approve a drug for which preliminary research barely demonstrated a positive effect, and later studies determined it to be ineffective. Another specialty association touts two drugs for treating early-stage Alzheimer's dementia, while neglecting to mention their ineffectiveness, limited patient eligibility, and serious side effects. Aside from creating “false hope,” these groups have done little for their members. Increasingly, hospitals, retirement homes, medical practices, etc. are not owned by people motivated by service, but by individuals or organizations interested in profit.
Making money in itself is not a bad thing, as even nonprofit organizations need sufficient cash flow to maintain operations, but when service is subject to wealth generation, patient care suffer from it. Reports on private equity institutions and practices consistently reveal, on average, lower quality care than in non-profit establishments: they employ fewer and less qualified staff, experience increased staff turnover, lower salaries necessary, perform more unnecessary tests and procedures, reduce equity and compromise patient safety. Health insurers, including Medicare Advantage (MA) plans, also demonstrate more interest in profit than in paying for patient services and, if necessary, cut benefits, increase monthly payments and patient co-payments, delay authorizations and prior appeals, deny necessary care and/or reduce the physician/provider's income. They often claim to be on the verge of bankruptcy, but invariably claim quarterly profits. One company, in a recent quarter, reported a profit of nearly $1 billion, while other companies touted recent quarterly gains of several hundred million dollars.
Conservative estimates of the behaviors of insurance and private equity companies cost the American taxpayer $400 billion to $450 billion annually and unnecessary deaths. For example, private nursing homes, which currently represent ±72 percent of total facilities, are estimated to be responsible for ±1,275 unnecessary deaths per year alone. Supporters of single-payer government programs have again asserted that they could be a panacea for many of our current health care problems, given a 2024 Congressional Budget Office report. could save between $42 and $743 billion, depending on the model chosen, and improve equity and results. A major area of reduction could be administration. Medicare spends ≈2 percent, while MA plans average ±13.7 percent. These programs already threaten to reduce services in response to a minimal decrease in Medicare payments in 2025, although reducing administrative costs could easily balance this reduction in payments without loss of services for clients. And yet, this assumption of superiority of a single payer is naive, because all countries with this system face problems: increasing costs of services, non-equity, reductions in basic services, less use of medicines/ advanced techniques, low professional salaries and widespread fraud.
In 2023, for example, the United Kingdom recovered $280.2 billion in fraudulent payments, or about 50% of such payments. Our problem is that we favor a laissez-faire approach to business and only enforce regulations after years of damage and public pressure. Regulatory agencies are chronically underfunded, leaving them unable to effectively enforce, in this case, existing regulations on health care insurers and for-profit ownership of health care entities. Citizens must pressure state and federal lawmakers to improve funding for agencies to increase enforcement. There will be significant industry opposition, and it will take time, probably years. But if we learn from the mistakes of others, we will improve our health system, improve equity and health, and save money.
Mr. Bennet Broner is a medical ethicist.