Murphys, CA…On May 7, 2017, Congressman Raul Labrador (R-ID) spoke at a town hall meeting with his constituents. He exemplifies the chutzpah of many in Congress: “No one dies because they don’t have access to health care”. Then there is the case of Chris Collins (R-NY). Just after the House of Representatives voted to “repeal” Obamacare and potentially cause tens of millions of Americans to lose their healthcare coverage, Collins was interviewed by CNN’s Wolf Blitzer. Collins, who voted to “repeal”, acknowledged he never read the bill upon which he voted. It brings to mind Aldous Huxley’s dictum, “Facts do not cease to exist because they are ignored.” (1926).

This is a series of eight articles on a single theme to be released once a week.  Copyright license granted under  

Over the past seven weeks, this series has offered an overview of the state of healthcare in America. In this last article, I summarize some of the key observations from this series and a few of the more important implications:

• We all want good healthcare.
  • We are all fragile organisms that are going to die, but we are self-conscious organisms that want to live.
  • There are thousands upon thousands of pathogens that can kill us, millions of possible genetic mutations that can do us grave harm, and even more accidents that could do either.
  • Good healthcare gives us the substantial possibility of improving our odds of living longer.

• Access to quality healthcare is critical.
  • Emergency rooms and doctor’s offices have more than 200 million visits a year.
  • There are 900,000 beds in hospitals for individuals that need more than an emergency room.
  • More than 38 percent of Americans will be diagnosed with cancer sometime in their lifetime. (National Cancer Institute).
  • Cardiovascular disease kills 800,000 persons a year and another 92 million are at risk or are recovering from a stroke. (American Heart Association).

• Healthcare is crucial to our economy.
  • Healthcare is the largest sector of our economy and accounts for 19% of our Gross Domestic Product.
  • It generates nearly twice as much revenue ($4.6 trillion) as all manufacturing ($2.4 trillion).
  • More than 12 million Americans are employed in healthcare, or 10% of the entire U.S. workforce.

• Healthcare delivery is complicated.
  • There are 900,000 doctors and surgeons organized into nearly 230,000 practices. Increasingly doctors are joining hospital (e.g., Stanford) or not-for-profit practices (e.g., Sutter). The complexities of multiple insurance and payment systems, regulatory reporting, and increasing specialization and technology, doctors are finding it advantageous to “go corporate”.
  • There are 5,500 hospitals in the U.S. and over half belong to a health system network. For example, Dignity Health runs 39 hospitals, while Adventist Health operates 20 hospitals. Moreover, the number of independent hospitals is declining dramatically as the result of merger, acquisitions, and bankruptcies.
  • With increasing specialization, laboratories, clinics, pharmacies, diagnosticians, medical equipment, anesthesia services, etc. are provided by different providers who have different billing systems, insurance coverage, and liability coverage.

• Healthcare funding is fractured.
  • One of the most unique features of the American model of healthcare is the reliance on market-based funding. Healthcare services are priced by the originating provider (doctor, hospital, etc.), but what fee that provider actually receives is set either by an agreed-upon contract amount the provider makes with an insurance company covering a specific patient or by a fee established by the government for covered classes of patients (seniors, the poor, disabled, etc.). A patient with no insurance will be billed for the original (and usually much higher) amount set by the provider. A patient covered by insurance plan A may pay a different amount from a patient covered by insurance plan B, which in turn is likely to be quite different from the price charged to a government covered patient.
  • Some patients discover that being covered for services in one part of a hospital network (e.g., an emergency room visit) may not be covered in another part of the same network (e.g., outpatient laboratory tests).
  • A majority of individuals over 18 and less than 65 years of age are traditionally covered through their place of employment, but this proportion has fallen from 65% in 2000 to 52% in 2015.
  • If you change from one job to another, it is highly likely the insurance coverage will also change, and along with it, the providers which you can use.
  • If you are unemployed, self-employed, or a low-wage employee and do not receive health insurance, you can show up at a hospital emergency room and get “charity care”, which is reimbursed from public funds.
  • If you become unemployed, you may stay on your former employer’s insurance plan for a set period of time (COBRA) by paying the full cost of insurance. But if you do not find employment with coverage at the end of the COBRA period, you lose all health insurance coverage.

• American healthcare is outrageously expensive.
  • Americans spend more for healthcare than any other country — $9,451 per person. The second highest expenditure per person is Norway with $6,567. Japan, with one of the best health systems in the world, spends $4,951 per person.
  • Perhaps even more shocking is that the U.S. uses 19% of its Gross Domestic Product (total national income) for healthcare, while Norway only invests 9% and Japan 10%.

• People do die from poor healthcare.
  • What we get from that steep investment in healthcare is surprisingly not all that much. Our expected lifespan ranks only 42nd in the world. While some Americans love to criticize the Canadian healthcare system, Canadians live longer than us.
  • Because we have traditionally run our medical system as a factory that responds to symptoms rather than a value-based service emphasizing prevention, many of our performance numbers have been getting worse rather than better.
  • Healthcare performance is also related to economic health. “A large segment of white middle-aged Americans has suffered a startling rise in its death rate since 1999, according to a review of statistics…that shows a sharp reversal in decades of progress toward longer lives. The mortality rate for white men and women ages 45-54 with less than a college education increased markedly between 1999 and 2013, most likely because of problems with legal and illegal drugs, alcohol and suicide, the researchers concluded. Before then, death rates for that group dropped steadily, and at a faster pace. An increase in the mortality rate for any large demographic group in an advanced nation has been virtually unheard of in recent decades, with the exception of Russian men after the collapse of the Soviet Union.” (Washington Post Nov. 2 2015).
  • Before Obamacare, it is estimated that 45-50 million Americans did not have health insurance. According to the non-partisan Congressional Budget Office, the so-called Trumpcare plane would result in 24 million losing health insurance. Does it make a difference? According to the American Journal of Public Health, those without insurance have a 40% higher chance of dying from health-related issues in any given year than those with health insurance. So yes, Congressman Labrador, the lack of health insurance can kill you.
  • Healthcare in rural communities is not keeping up with the demand. Rural hospitals are failing and closing at an alarming rate.

• Healthcare policy is brain dead.
  • As this is being written, a small group of Senators have been closeted away trying to draft legislation that would shape the entire healthcare system in the United States. Donald Trump once asked, “who knew it was so complicated?” The American Medical Association and the American Hospital Association have both pleaded with Congress to fix, not replace, Obamacare. Yet, a small group of Senators think they know better.
  • Perhaps more important is the difference between market-based healthcare, universal healthcare, and single-payer health care:
    • Market-based funding — the model of healthcare since World War II — presumes that the employer is the best source of coverage through private insurance. By 1965, it became clear that seniors who no longer work and those who are unemployed do not have access to this form of healthcare financing. As a result Medicare and Medicaid were created to fill the gaps.
    • Universal healthcare — Obamacare — is premised on the fact that additional gaps have been generated in the economy because increasingly the emerging job market does not offer health insurance — retailers, fast food chains — or the large number of self-employed. Fewer than 50% of those employed no receive employer-based health insurance. But universal healthcare is like sticking your fingers in an ever failing dyke. More and more gaps or leaks appear and failure is inevitable.
    • Single-payer healthcare guarantees that if you meet basic, non-discriminatory conditions, you are guaranteed access to healthcare. There are no insurance companies and no middlemen siphoning off life-giving resources. In many countries, even prescription drugs are included in these programs.

• How can we fix it?
  • Our fractured healthcare system is in the state it is primarily for one reason — it meets the business needs of the health insurance industry. Professional medical groups agree that we need major reform that moves towards a more holistic healthcare system. The major source of disequilibrium in this market is largely attributable to the ever larger and dominant, for-profit health insurance companies. They are the primary opponents of healthcare funding reform.
  • The numbers on a single-payer universal healthcare system are still out, but the momentum for such a system is alive and well in California. The State Senate passed SB 562 and moved it on to the Assembly.
  • There are many questions that need to be asked about the implementation of a system — for example, will the Federal government waive the use of the Federal funds for this system? Is the funding model predictably solvent? There is a question as to whether such an entity should be a not-for-profit corporation created by the State or another state agency.
  • We need to reform the healthcare system in this country — a system that makes the value of service as important as its cost.
  • Granted, there is a nearly insatiable demand for healthcare. The question isn’t whether everyone has a right to all the healthcare that is possible, but rather it should be possible everyone has access to healthcare. Perhaps there should be conditions for this access — no cigarette smoking, for example. But people who become ill from exposure to toxic chemicals, like farm workers or miners, or gardeners and lifeguards who get melanoma from increasing exposure to the sun should have ready access to appropriate treatments. Many do not.
  • Rural areas, which are losing their hospitals and doctors, should receive financial support to get quality healthcare.
  • Healthcare is a universal right derived from the promise of our Declaration of Independence — the universal right to pursue happiness. Not a privilege, but a right!

Author: John MacWillie is a native of Calaveras County, California. He graduated from UC Berkeley where he studied European history and bio-engineering. His graduate studies include economics and urban planning at New York University and philosophy at San Francisco State. He received his Ph.D. from the University of Leeds in the U.K. He worked for ten years in law enforcement policy and administration in New York City, spent nearly thirty years as a senior executive in the software industry, primarily in information security, and for the past twelve years has been teaching in undergraduate and graduate programs at California State University — East Bay in multimedia, art history, and criminal justice. He resides with his wife, an attorney, in Murphys CA.