The Congressional Budget Office has just come out with its scoring for the Republican version of healthcare, which is really less a healthcare bill than a tax cut for the wealthy of quite striking heartlessness. The CBO’s projections, just to give a taste of what its implementation would mean are that as early as 2018 an estimated 14 million people under the age of 65 would be without insurance, and that by 2026 that number would rise to 23 million — the number that is generally getting the most attention. Most of the commentary one reads and hears on healthcare is about who’s covered and how much will it cost. Excruciatingly important to be sure but actually just a piece of the puzzle. Quite apart from the cost to a particularly individual is what kind of healthcare are we really talking about?
In the United States we spend 17.8% of our nation׳s Gross Domestic Product (GDP), about 18 cents out of each dollar on healthcare. This works out to numbers so large as to be fantastical, a total of $3.2 trillion, $9,990 per person on healthcare. In the world community these are sums so disproportionately large as to be considered a statistical outlier—a thing unto itself. The data on the rest of the world׳s developed countries shows healthcare costs all within a general range. According to the Organization for Economic Co-operation and Development (OECD) the per capita average spent on health care among the 33 developed OCED countries is $3268. In the United States it is $8223. France, which according to WHO has the best healthcare in the world, spends only 11.2% of its GDP on its health system. And what does our grossly disproportionate expenditure buy us?
The World Health Organization reports, “The U.S. health system spends a higher portion of its gross domestic product than any other country but ranks 37 out of 191 countries according to its performance.” The Commonwealth Fund, which incorporates the assessments of both patients and medical staff in its calculations concludes “the United States ranks last overall among 11 industrialized countries on measures of health system quality, efficiency, access to care, equity, and healthy lives.”
Like OCED the fund also estimates the costs of the American health system and comes up with similar figures. Commonwealth: “While there is room for improvement in every country, the U.S. stands out for having the highest costs and lowest performance—the U.S. spent $8508 per person on health care in 2011, compared with $3406 in the United Kingdom, which ranked first overall.” The other countries in the Commonwealth study were Australia, Canada, France, Germany, the Netherlands, New Zealand Norway, Sweden Switzerland, and the United Kingdom.
When you assess the costs and the outcomes it is obvious something is deeply awry. To produce this kind of outcome data some other priority must trump wellness as the goal of health service in the United States. I think the answer is that profit is the essence of the U.S. healthcare system, that uniquely we have an illness profit system, and it is failing us dramatically. Not just in the issue of coverage but in the system that coverage, however payment is sorted out, provides the patient.
The proof of this can be found in the major defining characteristic of the American system: shortages. The U.S. system is one defined by its shortages. In the debate of Trumpcare or Obamacare you rarely see this discussed even though, as any health care professional will tell you. Shortages haunt every medical practice, clinic, and hospital.
Start with physicians. According to the OECD the average number of physicians per thousand people in the 33 developed nations belonging to the OECD is 3.1. In the Unites States it is 2.4. How does this translate in terms of actual practicing doctors? How certain are we that projections will become reality? In 2015 the Association of American Medical Colleges (AAMC) published the results of their extensive survey, The Complexities of Physician Supply and Demand: Projections from 2013 to 2025. In it they found, “Demand for physicians continues to grow faster than supply, leading to a projected shortfall of between 46,100 and 90,400 physicians by 2025.” A year later in 2016 , they published an update which showed an accelerating trend, “Physician demand continues to grow faster than supply leading to a projected total physician shortfall of between 61,700 and 94,700 physicians by 2025. As with the 2015 projections, under every combination of scenarios modeled, an overall physician shortage is projected.”
The physician shortage is especially problematic in rural areas, where more than 20% of the U.S. population resides but only 10% of physicians practice, according to the Association of American Medical Colleges. According to the Migration Policy Institute, “In 2010, the foreign born accounted for 16 percent of all civilians employed in health care occupations in the United States. In some health care professions, this share was larger. In 2012 more than one-quarter of physicians and surgeons (27 percent) were foreign born, as were more than one out of every five (22 percent) persons working in health care support jobs as nursing, psychiatric, and home health aides.”
This already difficult situation is about to get much worse as a result of a February executive order of President Trump’s. According to the American Medical Association (AMA) Trumps’s executive order is going to have a devastating effect. There are more than 8,500 actively practicing physicians in the U.S. from Syrian and Iran, two countries on the the Trump list. Close to 50,000 physicians practicing in the U.S. are from India. The rising racism, tribalism, identitarianism, call it what you will encouraged by the administration is making many of them and their families very uncomfortable, according to a report in Scientific American. They report a growing number of doctors who wished they had gone to Canada or the U.K.. Those on H1-B visas are advised not to leave the country for fear they will not be able to return.The net result of all this will have a very negative effect on the wellbeing of Americans as a people.
The MD shortage however is producing an interesting unintended consequence: the transformation of osteopathic medicine. Only two types of physicians are fully licensed in the United States, osteopathic, and allopathic using two related but distinct medical models. Osteopathic physicians, for most of the profession׳s history, have been strongly associated with Osteopathic Manipulative Treatment (OMT) as it is called. While still taught it has fallen away as osteopathic colleges have structured their educational model to focus on primary and family care.
This may be good news for patients, who will be offered low-side effect alternatives before having to become involved with rigid and increasingly expensive pharmaceutical medicine. The osteopathic schools have been quick to pick up on this trend and have build new colleges placed near the areas where the doctors are needed. The report notes, “The osteopathic medical schools developed during the last decade are strategically located in areas where they can significantly improve the overall health of their communities.”
And the DO physician population is exploding: “The number of osteopathic physicians practicing in twelve states has more than doubled over the past decade,” the report notes, adding they are training physicians where they are most needed as the profession records a 62% growth rate for the same period. It is one of “the fastest growing disciplines in health care in the U.S.”
The data suggest that we will see part of the primary care physician deficit made up by DOs, and it suggests a rural healthcare system will arise increasingly staffed by osteopathic physicians, nurse practitioners, and PAs. I think this would be significantly assisted by the conversion to a wellness-oriented single payer system that is grounded in healthcare as a birthright.