Are We Backing into Universal Healthcare Anyway?

There are two macro-trends in healthcare, both of which began in pre-COVID-19 times, that suggest a rather dramatic unraveling at a grassroots level: the demise of the primary care (family) physician and the slow erosion of hospitals and doctors in smaller, mostly rural communities. COVID-19 just made the whole healthcare erosion process that much worse. At the core of the problem is the fact that hospitals and doctors must earn at least enough money to cover their costs plus a reasonable return. For rural doctors, that would be a living salary. Where the numbers do not sustain a hospital or a medical practice – whether it’s because the community is too spread out or small or perhaps because its residents simply cannot afford healthcare – doctors move and hospitals close.

“It’s a pattern that is likely to play out across the nation as COVID-19 unsettles the precarious finances of hundreds of small rural hospitals. Already, more than 170 have closed in the last 15 years, according to the University of North Carolina’s Rural Health Research Program. Last year, 18 shut down — the most since 2000 — and 12 have closed in the first four months of this year.

“‘It’s hard to envision a scenario in which we do not see a lot more hospitals closing,’ said Alan Morgan, chief executive of the National Rural Health Assn., adding that in February, the nonprofit group identified more than 400 hospitals at risk for closure. ‘Things have only gotten significantly worse.’

“According to a recent report by the American Hospital Assn., hospitals and health systems across the U.S. face unprecedented financial challenges in the coming months, with an estimated loss of more than $200 billion from COVID-19 expenses from March to June… After canceling all outpatient and elective procedures, which account for 70% to 80% of revenue, Morgan said, many hospitals are furloughing and laying off staff. In April, the healthcare sector lost 1.4 million jobs, according to the U.S. Bureau of Labor Statistics, with nearly 135,000 hospital workers laid off across the nation.” Los Angeles Times, May 19^th.

Charity isn’t enough. Hospitals just don’t work well in communities that cannot afford them. Rural doctors are becoming a rare breed too. They cannot sustain a practice where there are either too few patients or no money to pay doctors, both plights in conservative rural communities. Often in red states that have opposed the expansion of Medicaid and made it a point to deny universal healthcare by calling it socialism.

But our healthcare system is also beginning to make doctors even in more financially viable communities worry about their earning power. A whole lot of doctors, traditionally well-paid even where managed care is pushing dollars down, have been fiercely fighting against universal healthcare initiatives that are very likely to impose standardized fees for various procedures. Many, carrying staggering debts associated with getting their doctorates, are forced to work for years at decidedly lower levels of compensation (often well below what is paid to nursing staff) during post-graduation periods labeled as “residencies” and the more senior “fellowships” to qualify for specialization. They are holding out hope for that pot of gold (a bit less of late) that they were promised in medical school. And while they may hate the pharmaceutical and insurance stranglehold on the healthcare sector, they also have recognized that such institutional opposition to universal healthcare has only bolstered their own political preferences against that eventuality. And then came COVID-19.

Many states have banned “non-essential” medical procedures, pushing many specialists out of their normal (and often lucrative) practices. Hospitals lost that business too. Generally, people are also loath to visit any medical office or an ER, for fear that patients with the virus may have been in the same place. Reports that the number of strokes being reported have fallen significantly have led many physicians to fear that people are under-reporting such occurrences to avoid seeing doctors or visiting emergency rooms, filled with COVID-19 victims. COVID-19 is also pulling physicians away from many specialties (where many patients have been told to wait until the crisis passes anyway) into critical care facilities, placing them into harm’s way with inadequate supplies, equipment and personal protection.

To make matters worse, the financial patterns for that “medical canary in the coalmine” – the primary care physician – are beginning to unravel the sustainability of that family practitioner, a cornerstone of American medical care. There are indications that such medical practices just might not survive without the steady income flow that a universal healthcare system might generate. Noam N. Levey, writing for the April 14^th Los Angeles Times, explains:

“Doctor groups and insurers say in [March alone], there’s been a dramatic surge of interest in large-scale changes in the way primary care doctors are paid, an overhaul that policy experts have envisioned for decades… ‘I’m a little amazed,’ said Shawn Martin, vice president of the American Academy of Family Physicians. ‘The sense of urgency and financial instability brought on by the crisis has accelerated ideas that we have been noodling on for years.’

“Driving the urgency is a dramatic drop-off in patient visits to primary care practices over the last month as the coronavirus spread and patients stayed away from the doctor’s office, fearful of getting ill… Primary care doctors have seen a big uptick in telehealth visits — a move widely hailed by public health experts. However, the fees for these services are often lower than for office visits… Many physician practices have seen in-person patient visits drop 50% or even 75%. That has left physicians struggling to stay afloat and forced growing numbers to consider laying off staff or even closing.

“Nearly 8 in 10 primary care clinicians in one recent survey reported their practice is under ‘severe’ or ‘close to severe’ strain because of COVID-19, the disease caused by the coronavirus… To deal with that problem, the federal Medicare program and some commercial health plans have begun offering advance payments to medical providers, effectively giving physicians a lump sum based on an estimate of how much they would expect to collect from seeing a normal stream of patients.

“Many experts in the healthcare system see that as a first step toward redefining the traditional office visit, expanding telehealth and abandoning the age-old system of paying doctors for each service they perform… That would mark one of the first clear examples of how the coronavirus outbreak — and the gaps it has exposed — may catalyze profound changes in the healthcare system.” If primary care physicians are gone, people will instead overwhelm hospital emergency room with demands that hospitals are not equipped to handle. We are not remotely prepared for that.

On yet another level, knowing that pandemics are likely to continue (think: COVID-19, SARS, MERS, Ebola, HIV, Zika, H1N1, cholera as the beginning of a chain, exacerbated by climate change), individual insurance carriers, hospitals and even state-supported healthcare exchanges are probably not sufficiently structured or capitalized to handle rolling pandemics. Presently, we’re seeing governments at every level providing financial support gratis. The Army Corps of Engineers was forced to turn large venues into hospitals. Military hospital ships are on each coast. States, and governments are buying medical supplies and equipment to be given to treatment centers all over the United States. Seeds of universal healthcare?

Historically, where there has been a need for risk pooling but a lack of private capacity to provide that support, the government has always stepped in. Flood or earthquake insurance. Federal Deposit Insurance Corporation covering most bank failures. The federal Pension Protection Act of 2006 (using the Pension Benefit Guarantee Corporation) guaranteeing pensions. The Federal Reserve with quantative easing and funneling money into the banking system. Federal bailouts of critical industries. Etc., etc., etc. Isn’t universal healthcare just another form of risk pooling?

Structuring big-ticket healthcare coverage for pandemics – something gathering support on both sides of the aisle in Congress, if implemented – will obviously lay the infrastructure for universal healthcare anyway. Add that to what we are already doing as noted above. And if we do not adopt massive additional federal support for COVID-19 medical costs, the way we have embraced stimulus legislation, there will be two clear losers: those who cannot pay for their healthcare and the entire US economy for the foreseeable future. How we pay doctors, mostly to handle sickness, seems archaic where keeping people healthy on an on-going basis is probably less expensive and more effective. The staggering costs of getting a medical degree also make no sense; it distorts the process from its inception. Six figure student debt is ridiculous.

It’s time for universal healthcare. It’s time for the special interest groups with any vestige of resistance to step aside. Now. Not haphazardly but sustainably. Individual medical costs are not an issue in any other developed country on earth. Funny when you take making a profit out of the equation how reasonable medical costs become and how many people no longer live in fear of medical emergencies or medical bankruptcies.

            I’m Peter Dekom, and when will the obvious ever be more obvious than it is regarding the implementation of universal healthcare here in the United States, just the way it has already been implemented in every other developed nation on earth.