The U.S. Healthcare System: How did we Get Here, and Where are we Going?

Tomorrow marks the 241st  anniversary of our Declaration of Independence from the Brits. On July 4, 1776, the Second Continental Congress affirmed that the 13 colonies were a sovereign nation, with Thomas Jefferson serving as lead author role in penning the document later signed by 55 others including notables Benjamin Franklin, John Hancock, John Adams.

Years later after a bloody war, on September 17, 1787, many of these came together in Philadelphia to ratify the Constitution that would govern our land. Its Preamble resonates then as now: “We the people, in order to form a more perfect union, establish justice, insure domestic tranquility, provide for the common defense, promote the general welfare, and secure the blessings of liberty to ourselves and our posterity, do ordain and establish this constitution for the United States of America” But from that day forward, our democracy has been a work in process as evidenced by the 27 amendments added and 6 pending ratification since its signing.

I have carried a copy of the Declaration and Constitution in my briefcase for years, occasionally referencing it when policymakers and pundits reference the intent of our founding fathers. Though prominent signers like Benjamin Franklin and Benjamin Rush dabbled in health services, neither document provided a blueprint for the healthcare system our forefathers envisioned. Likewise, the Declaration and Constitution do not lay out how our banking, education or transportation systems should operate. Rather, they provide principles for how our Republic is to govern commercial activity leaving it to the states, Congress, and Executive branch to pass laws, and the Courts to adjudicate disagreements.

In the Preamble to the Constitution, there’s reference to “general welfare” but no footnote contextualizing it as a system of care that’s universally accessible, affordable or safe, or the distinctions between healthcare programs and human services. It doesn’t reference doctors or hospitals, Medicare, Medicaid, insurance or even cures. That’s the genius and limitation of what our forefathers produced 241 years ago and why opinions today about the health reform debate provoke such a wide range of opinion and emotion.

The authors of the Declaration and Constitution believed health and healthcare were the domain of families who tended to their own. Historians observed that few trained clinicians made their way to the new world. Thus, physicians were self-trained via an apprenticeship model. Caregivers were unlicensed and well-intended. Hospitals borrowed from 11thcentury Britain’s pest houses for those with contagious diseases like smallpox and almshouses for the old, sick and poor.

But as innovations in care progressed (handwashing in the 1840s, antiseptics in the 1850s, bacteriology in the 1860s, et al), the need for formal training became apparent. Two sentinel events bridged the transition toward the modern system we now have: the founding of the American Medical Association in 1847 to ensure the profession could control its own destiny and the Flexner Report (1910) which set forth principles for medical education of physicians.  Then, as a by-product of World War II, specialization became synonymous with “modern medicine” and having insurance the mechanism whereby employers and individuals could afford their services. The Hill Burton Act (1946) assured a hospital in every community, and over the AMA’s objection, Lyndon Johnson’s Great Society program creating Medicare and Medicaid became law in 1965.

It’s hard to imagine our forefathers envisioned a system as complicated and powerful as we have today. At the turn of the 20th century, it was 4% of our GDP; today, it’s almost 18%. Then, physicians were the centerpiece of the system; today, they’re key players but not the sole source of truth. Then, ‘we the people’ were patients dependent on the recommendations of clinicians and family members; today, we’re guided by integrated care teams, social media, smart devices, artificial intelligence, precision medicines and coverage policies of insurance companies.

Last Thursday, at the annual meeting of the Michigan Health and Hospital Association on Mackinac Island, a gentleman asked “what’s the future for our system?” The context of his question was the contentious debate about the Senate’s Better Care Reconciliation Act and the broader theme of health reform that’s dominated news in recent weeks. My response was this: we’re likely heading toward regional integrated systems of health that provide both delivery and financing of health on an at-risk basis to populations. But getting from where we are to there is a messy process.

The laws that regulate the transition from where we started to where we are today often seem to lag clinical innovations that improve how we diagnose and treat, technologies that define how we live our lives and marketplaces that extend beyond geographic boundaries. And the politics of healthcare—pitting a majority that see access as a fundamental right and a significant role for government vs. a minority who prefer a lesser role for government and greater role for individuals—divides us. Who could have anticipated the acrimony that’s standard fare, the fuzzy math that supports facts and alternative facts or the notion of fake news. The Congressional Budget Office's score last week that the Better Care Reconciliation Act (BCRA) would result in a 35% cut in Medicaid funding over the next 20 years was discredited in a nano-second after its release even as GOP Senators went home to answer constituent questions about what’s next for healthcare.

Healthcare in the United States is complicated. Our forefathers did not cut and paste from a structure they felt accomplished its societal aim. It evolved as a home-grown reaction to events and circumstances uniquely American. Our forefathers set forth principles for its oversight under the premise that government’s role is to “promote the general welfare”. They did not envision many of its players—drug and device manufacturers, technology providers, insurers et al would operate global enterprises as mega-businesses. They did not delineate between health and human services programs, nor anticipate it would employ 17 million, provide coverage for one-third of the population and constitute 30% of our federal budget. They assumed laws would stabilize transitions from today to tomorrow, and they bet on the courts and public opinion to correct miscues and bad policies along the way.

Thus, laws like the Health Maintenance Organization Act of 1972, the Patient Protection and Affordable Care Act of 2010 and last year’s 21st Century Cures Act were passed to fix current problems.  But they have not resolved the bigger question about the long-term future of our system.

Where we’ve been seems clear in retrospect. Where we’re heading is unclear. But until and unless that vision is understood and supported by “we the people”, our democracy will flounder in search of an answer.
 
Paul

P.S. Next week, the Senate returns from its break and will attempt to pass its BCRA version 3.0 legislation. Insurer announcements about premium increases will garner media attention as will the trial of Turing Pharmaceuticals CEO Martin Shkreli in Brooklyn wherein the company’s 5000% price hike for Daraprim will be in spotlight.