The Questions We Punt
by Alan Sager
April 16, 2020
This interview with Alan Sager, a professor at the Boston University School of Public Health, where he has taught since 1983, was conducted and condensed by frank news.
There is a misconception that closing hospitals saves money – why do some insist that's true?
It seems logical and feasible in the abstract; fewer beds and fewer hospitals sounds like it should equate to lower costs. Closings have been pushed for eight main reasons.
Politicians have to look like they are trying, and when politicians are closing hospitals, it looks like they are trying to contain cost.
If the only tool you have is a hammer – every closing looks like a nail. You can turn Stephen Berger loose on hospitals in the 1970s, and you could have a Berger commission decades later, and it looks like you're doing something when you are really just repeating the same stale and failed policies.
Health care cost control is something that Americans in healthcare claim to care about, but don’t actually care. If we did, we would enact policies that were actually effective and not continue to insist on hospital closures. Support for cost control is probably a mile wide and an inch deep.
Also, the hospitals that expect to survive, may sometimes support the closure of other hospitals. There's a belief that competitive forces will be sufficient to do the job of weeding out ineffective services, but competition requires competitors, the more the better, and any closing or any merger reduces competition. Which allows the survivors to raise their prices. The pace of mergers in New York City and the consolidation has been very rapid in the last decade. Unfortunately, the hospitals that close tend to be the less costly ones. If the patients displaced by closings obtain substitute care, that's often available only at the very expensive major teaching hospitals that are rarely forced to close.
Right. And the hospitals that did end up closing affect black and brown communities disproportionately.
Well that's right, hospitals nationally are more likely to close in black and brown neighborhoods.
Across the 52 cities where I track data on 1200 hospitals, race is a much bigger factor than ethnicity.
That is partly because a significant share of Latino citizens are located in Southwest cities where the physical shape of the city makes it easier for patients to move by car from one neighborhood to another. But in a place like New York, both ethnicity and race are certainly strong factors.
Black and brown people in New York City have been disproportionately hurt by hospital closings because they lose both inpatient care and emergency room care. And there are harmful ripple effects: when a hospital closes, the doctors that have remained in private practice in the surrounding neighborhoods are more likely to retire or relocate. We see this in city after city.
You also found black patients much more likely to go to the ER.
Yes, in national data, black patients are twice as likely as white patients to rely on the hospital for the doctor visit, whether that is for primary care, an ER visit, or for outpatient clinics. One third of visits by African Americans to see a doctor are visits to a doctor housed in a hospital. When you lose a hospital, you lose all of that care.
In many cities you have enormous expanses of medical deserts. Detroit has four hospitals for an area three times as big as San Francisco or Boston. In East Brooklyn there are very few hospitals or emergency rooms. There are a total of two in the entirety of Southern Queens – Jamaica Hospital and St. John's Episcopal in Rockaway. Queens has two and a half million people just by itself, it’s huge. One of the reasons we allow this to happen is that American healthcare is prejudiced toward raising the ceiling, not raising the floor.
We are focused on improving the best we can do for some people rather than improving the worst we tolerate for anyone.
Why do you think that is?
Well, in the abstract, we're committed to equity and we really care about it. That shows up clearly in public opinion surveys. But when decisions are made at an institutional level, the major teaching hospitals take priority. Major medical centers / teaching hospitals are disproportionately likely to survive. Smaller and mid-size community hospitals are much likelier to close. Decision makers are thinking about the Nobel Prize, about how they can push back the frontiers of medical knowledge. That's not evil. They are committed to saving lives, but they're not thinking about the question of what care is affordable for all Americans. That is a political and financial and ethical question that our country consistently punts.
We sometimes imagine that a functioning, competitive free market will give us the hospitals and doctors – the right numbers and the right types in the right places. I'm okay with free markets where they work, but they simply do not work in healthcare. Not a single one of the six requirements for a functioning free market is remotely satisfied in healthcare. We can't trust the free market here. But our nation’s long held faith in the private market combined with a legacy of public sector incompetence, leaves us with no functioning market and no ability for governments to act competently. Without either a market or a government that works, you have anarchy.
Anarchy I think is the compelling word that describes the shape of U.S. health care. Anarchy is why, with $4 trillion spent on healthcare, we fail to have a really decent solid floor of health care for all, below which we don't let anyone fall.
How does the closing of hospitals affect outcomes today? How are we seeing the choices already made play out in this pandemic?
We have large expanses in New York City where there are no hospitals and very few doctors – neighborhoods where there is a high share of citizens who don't have a doctor they know and trust. That basic trust in healthcare is a personal and critical one. When the doctors are gone, people in crisis don't have that relationship that carries them into healthcare. When a person lacks a doctor they can consult with, someone they can reach by phone to ask – “what should I do when a fever or shortness of breath hits?”
The lack of a trusting relation with a family doctor can undermine people's willingness to self isolate, to stay at home, to keep a physical distance.
These large urban areas without hospitals and with few doctors has put healthcare out of touch for a large proportion of Americans. I don't mean to make it sound mystical. Healthcare is personal and human. It's not a machine whose hospitals and doctors are interchangeable parts. Place and people and race and income all matter, and we have ignored that.
Do you think it's possible to move back to a mode of community health care? To create a better relationship between patients and their healthcare providers?
If we made a commitment, as a nation, to have a family doctor for every patient that wanted one, we could certainly do that. Let me go through a few numbers with you.
Suppose we decided to pay $300,000 a year income for a family doctor for every American. And suppose we got really crazy and said we're going to drop panel size for family doctors from 2000 or 2,500 to only 1,000 – so those doctors have time to connect with patients, to follow up and ensure continuity of care, to network with other doctors. That is old fashioned primary care. If we wanted a family doctor at that rate, we would need about 300,000 primary care doctors. That would cost us $90 billion a year. We're spending about half that now. $90 billion during the year is not even two and a half percent of healthcare spending.
And good primary care really does save money. It means fewer lab tests, less imaging, fewer specialist referrals, fewer ER visits, and a diminished rate of intake of inpatient care. Some people have complained about “excessive use” of the emergency room for decades. The ER is nobody's first choice for basic care. Sitting in a crowded room with people coughing on you is not good care. People go to the ER because they don't have a better choice they can rely on.
Rebuilding primary care is something we should do, and something we can afford to do.
We have to find ways of channeling enough of this year’s $4 trillion in health care spending into primary care. Today, high medical school debt, low income, and low prestige of primary care, and many other factors make rebuilding a network of primary care for all Americans challenging. But we're good at challenges, when we decide we want to take them on.
A big barrier to rebuilding neighborhood level of care is the public health world. Public health now talks about social determinants of health, like income, education, job training, transportation, environment, criminal justice, nutrition. Those are all crucial. But let’s look at the key numbers. We have a $22 trillion economy and healthcare is $4 trillion out of that. Most of the remaining $18 trillion already goes to the social determinants like food, housing, transportation, education and job training. The money is not spent well – and not equitably. But vast sums are already there to address social determinants. It needs to be spent better and more fairly.
Medical care is about taking care of sick people, and if many public health folks continue to fall in love with social determinants and imagine that most or all medical care is about prevention, they are going to continue to allow those who shape the spending of the $4 trillion to spend it very badly. The result will be to enable three very bad things to persist—the focus on raising the ceiling, the waste of health care resources, and the inequality inside medical care.
Just as bad, it is futile to talk about “social determinants” without identifying any feasible way— politically and financially—to get the hundreds of billions of new dollars to address them. Especially in a nation where higher health care spending sponges up $200 billion more each year. Without health care cost control, how will it be possible to find serious new money to address those social determinants? And so, probably, are attempts to insure all Americans.
You know, it's an interesting thing you point out, because of those we’ve interviewed in the public health space for this issue, many make the point you just discounted. Which is, if we ignore the social contributions to overall health, we cannot make people healthier. I think it's a really interesting distinction to make in terms of funding.
Yeah. I’m not discounting the social contributions to overall health; I’m just insisting that medical care isn’t very good at making those contributions.
I am really suggesting that what doctors and hospitals know how to do is take care of sick people. That’s essential, since prevention has a 100 percent failure rate. And the quicker doctors diagnose people who have serious problems, the better we can help them avoid deterioration, high blood pressure, diabetes, obesity. Trouble is doctors are not very good at helping us lose weight and it goes so much to factors that most medical care really doesn't help with. Most social determinants are products of economic insecurity and legacies of economic and racial and ethnic discrimination. But healthcare doesn't really know how to effectively address any of that.
No I did not.
No one knows that.
Why is that such a secret?
Well, because no one pays attention.
Healthcare for all Americans should be the easiest problem to fix because it's the only one on which we spend enough money.
Is it enough for immortality? Probably not, since health care has the same 100 percent failure rate that prevention does. But it's enough for medical security, which is a phrase the late Senator Ted Kennedy often used .
Medical security means when you're sick or injured – getting quick, competent, appropriate and kind care without worrying about the bill. And 4 trillion bucks is enough to do that. If your family doctor’s panel of patients were one thousand, I imagine they could be a good channel to refer you to AA or Weight Watchers or a good social worker. I think that's a good way – a patient-by-patient individual approach to addressing social determinants. But saying that public health or health care can handle income redistribution, education, nutrition, housing, job training, criminal justice and the environment is delusional.
If you take your eye off the ball and you stop insisting on healthcare equity, you allow the well-intentioned but misdirected people who channel healthcare spending to control the only money that can go towards assuring medical security. The power then goes to people who are focused on the ceiling rather than the floor.
You wrote ‘the US appears addicted to more money for business as usual,’ which I thought was a succinct way of describing the politics of all of this.
Well, I think it's true. Nobody's evil in this; there are no villains, I think.
Our country began to cover people when the economy was booming in the 40s, 50s and 60s, and we didn't build in any cost controls. Other rich democracies raise the money for healthcare overwhelmingly through taxes. When you have to raise the money through taxes, two things happen. One, there's more of a built in pressure for equity, because it's public money. And two, there's a built in pressure for cost control because politicians don't like losing elections, and raising taxes is the best way to lose elections. When you have tax financed healthcare, you are going to be way more interested in controlling the costs of hospitals and doctors and drug companies, meaning that those actors will have to make much more careful decisions about what they're doing and who gets it.
$4 trillion translates into the U.S. spending more than double the rich-democracy average per person. And those other nations in the OECD typically provide substantially more doctor visits, more hospital admissions—for half the money. And they live longer. Not bad. By some estimates, you could say that half of the $4 trillion we spend today is wasted. It is wasted on care that is not needed, care that is botched, high prices for drugs and much other care, and administrative, and paperwork waste (which stems from multiple payers and complexity—and great mistrust between caregivers and insurance companies).
I feel optimistic about healthcare because the money's there, we just have to resolve to spend it a little better.
The primary was very contentious in terms of each candidate's take on healthcare. How do you look at the national conversation? Do you feel like it's helpful? Do you feel like there’s a right solution? Do you wish it was an entirely different conversation?
I think it's mostly unhelpful. I think it deals mostly with abstractions, like "choice of insurance company" or "single payer." These are probably the least attractive political slogans you could imagine. Let’s substitute "health care for all" for “medical security for America.” You take that and you start to think, how do we make sure we have the right kinds of doctors, the right number of doctors, in the right kinds of places. And the right numbers and types of hospitals in the right places, both urban and rural. I fear that single payer is an abstraction. And it’s a big jump in a country where people don't trust the government.
The French government, for all its various oddities, has a completely different sense of accountability than the U.S. Pres. Macron said a few months ago that the government was going to pay the salaries of 200 family doctors to move into underserved urban areas, and 200 more to move into underserved rural areas. The government of France feels responsible for making sure every citizen of France has a doctor. That is the kind of talk —and action— that I think makes a difference.
For my entire adult life, I've listened to a faux debate about healthcare. Usually the argument stalls at, well, where's the money? This end point is, as you’ve explained, not true – we have the money.
Elizabeth Warren even explained how you shift the money from private insurance premiums into a single trust fund. In effect, she’d finance health care for all in large part by requiring maintenance of private effort—premiums from employers—but diverting that money into the trust fund that finances health care for all.
You don't want to take $1.2 trillion in private insurance premiums and convert that into the income tax or social security tax because people will get sticker shock. Nothing beats a 70 percent rise in the personal income tax as a way to get a politician defeated in the next election. However, if you simply take the aqueducts through which the private insurance money flows and hook them up, not to Blue Cross as the payer, but to the single trust fund, it's just a matter of re-piping the aqueduct for the last 20 yards. The money is there. The claim there was a $32 trillion shortfall in the Medicare-For-All proposal was totally bogus. That was the big insurance companies and their executives wanting to keep their jobs.
We know how to save money. If every hospital had a budget adequate to finance efficient delivery of needed care for all people, the hospital administrators and their assisting MBAs would sit down with the clinicians and say, how do we make this money last 12 months and take care of everyone? And that is how hospitals typically operate in other rich democracies.
Is there anything you want to address about what's happening with this pandemic?
We came into this crisis, as everyone now knows, unprepared, with inadequate reserves of equipment, clothing and masks. With a public health infrastructure that had been gutted over the last 40 years. Where the competent people who could have helped craft quick testing and quick contact tracing — and who would have been an effective force for quicker action generally — were not widely available. Dozens of thousands are dying. I think we have to resolve to do better next time. As President Lincoln said in Gettysburg on November 19th of 1863, those who fought consecrated the ground on which they died.
It would be sad and horrible if we allowed the next virus or other natural or human-caused disaster to reprise the events of the past and coming months.
That means rebuilding a vigilant public health capacity that provides accurate early warnings and quick, effective responses. And it means assuring affordable and high quality medical care and medical security for every American
We have to refrain from forgetting. We quickly forget. If hindsight really is 2020, we need to look back on what has happened, when things settle down, and remember what happened and why.