Articles

Dr. A. J. Layon Interview for Hudson

^{1: Can we fix a broken healthcare system?}
I’d like to thank you for the opportunity to deal with these questions, about which I have been thinking over the past 40 years.
To get to your first question: Can we fix a broken healthcare system? I will point out that the US healthcare system serves precisely the purpose, and functions exactly the way, that it was designed to. That is, the US healthcare system functions – in administrative speak – as a profit center rather than a cost center. Specifically, the design of our health system, in as much as there is an intentional design, is to provide services which enrich a handful of companies and individuals, resulting in the most expensive and poorest quality care in the industrialized world ₍₁₎. The reader may ask if I’m exaggerating, so let me specifically address a handful of broad issues and then go on to deal with this in more detail.
Firstly, the people who are involved in our healthcare system – physicians, nurses, nursing assistants, administrators, environmental service workers, everybody involved – get up in the morning, for the most part, wanting to do the best job they can; this is not a problem of bad people. Yet, as I suggest above, the health care system – indeed, any system – delivers the results for which it was designed. So, not withstanding our desire to deliver the best services we can, the data ₍₁₎ show, in a series of studies on the health systems of the richest 11 countries in the world from 2014 to 2022, that the US continuously comes in the last place, with the highest cost per patient, the highest cost as a percentage of GDP, the poorest access, the worst income-related disparities, and the worst administrative efficiency.
Additionally, in our country some 60% of bankruptcies are related to/due to medical debt ₍₂₎, although the formula for this calculation has been challenged ₍₃₎. That is, there are some 560,000 – 600,000 households that yearly declare bankruptcy secondary to medical debt ₍₂₎. This is unheard of in other industrialized, wealthy countries such as Germany, the Netherlands, Britain, France; this is an American phenomenon only.
As a component of this medical debt issue, and because of the profit center nature of our health system, pharmaceutical agents are multiple-times more costly in the US than they are in our peer nations – Canada, France, Britain, Netherlands, Germany, and so forth. More recently there’s been a shortage of cancer chemotherapeutic agents ₍₄₎, because to produce these does not generate “sufficient” profit for the pharmaceutical companies. This may not be a problem for you, perhaps, today, but it could be, and statistically will be for many of us who will, eventually, develop a malignancy. And it is a problem for our fellow citizens who have malignancies that must be treated; the consequences of not treating being, potentially, death.
Another consequence of our health system being organized around profit rather than service, is a general shortage of pediatric beds ₍₅₎. It’s incredibly difficult to argue that we should not be carefully guarding and protecting our most precious resource, our children. Yet the ability to find hospital beds for children is becoming more and more difficult in the US.
Finally, we cannot leave this general topic without commenting upon the difficulties and challenges in women’s healthcare. This is more than the very important issue of abortion rights, unavailable or extremely limited in some 20 States since the Dobbs decision ₍₆₎. Making abortion illegal only prevents safe abortions, not abortion. If our so-called “Pro-Life” friends really wanted to decrease the incidence of pregnancy and abortion, there are examples showing how to do this.
In the European Union, one of the countries with the lowest abortion – and unwanted pregnancy – rate is the Netherlands. In their national health system, sex education is vibrant and open, birth control is easily available, as are abortion services. And because, not in spite, of this the Netherlands has one of the lowest abortion rates in the EU. This is the model, not denying sex education, making birth control difficult to obtain, and making abortion illegal.
And, of course, we have multiple other issues that are medical, but have socio-economic inputs. In our United States, about 42% of the population in 2022, is obese. The infant mortality rate (per 1,000 live births) is 5.4 ₍₇₎ – much higher if you are poor or an ethnic minority – about 25% higher than the average in the industrialized/wealthy world. Maternal mortality in the US is the highest in industrialized/wealthy world, with 24 deaths per 100,000 live births – 2.5 to 3 times the average for peer countries – and double that if you are an African American woman. And we had one of the highest death rates during the COVID-19 pandemic, compared to peer nations _{(8, 9)}.
Thus, these are some of the issues we are faced with when we ask the question: Can this American healthcare system be fixed?
Nonetheless, it is important to ask the question, and to determine the ways in which we can leverage the functional parts of our health system into a whole that is patient centered, high-quality, minimizes waste, and provides satisfaction to the individuals who must use the services we provide. It is to this that I’ll address myself in the following questions.
^{2: Universal healthcare coverage: Implementing a system that ensures access to healthcare for all individuals, regardless of their financial situation. This could involve expanding public programs like Medicaid or creating a single-payer system. Your advice?}
The central principle of universal health coverage is everybody in, nobody out. With this as the goal that we seek to achieve, there are several ways to get there. The most cost effective and appropriate would be to have a Medicare for All (M4A) type system. With M4A, there would be, overall, a decrease in the money a family spends on healthcare. And coverage would be complete – medical, dental, hearing, physical therapy, rehabilitation/nursing home – compared to what we are provided with today. This would be, as is Medicare now, a government run insurance program, with hospitals, clinics, and physicians functioning as they do today. The immediate administrative savings would be significant. Work previously done looking at administrative overhead shows that for the federal programs – Medicare and Medicaid – overhead is about five cents on the dollar; for the private, for-profit health insurance industry, administrative overhead can be as high as thirty cents on the dollar. The administrative savings on the $ 4.3 trillion health budget in 2021 [$12,900 per person, 18% of our GDP] is quite significant and would be used to provide for the services to our people, rather than shareholder dividends and executive salaries.
There are other ways to get to a national health system. The German, French and Dutch systems are examples that use a mix of private, not-for-profit insurance companies and government financing.
^{3: What can healthcare systems do for cost control measures: Addressing the high cost of healthcare services and medications. This could involve negotiating drug prices, promoting competition, and implementing regulations to control healthcare costs? Health information technology: Improving the efficiency and coordination of healthcare through the widespread adoption of electronic health records and other technological advancements, will this work?}
This is one of the most challenging questions of this entire topic. How do we control costs? There are several tools we can use to get at this over, perhaps, the first 5 to 10 years of the life of a national health system. I utilize this time-line because, initially, costs would increase as there are so many people who have unmet health needs; when these fellow citizens start to use the national health system, costs will, initially and temporarily, rise.
Firstly, the provision of health care would no longer be a profit center; we would eliminate much of the profit motive from healthcare. If we were to only eliminate for-profit health insurance companies from the equation, as discussed above, we will have made a significant dent in the funds needed for the provision of healthcare to our people.
Secondly, while we have some remarkable pharmaceutical companies in US, much of what they do – not all, but much – comes from work that initially has been carried out utilizing funds from the National Institutes of Health, and/or the National Science Foundation. Discoveries made using our tax-payor generated funds are then licensed to pharmaceutical companies and they are allowed to patent the drugs that come from this work; significant financial advantage thus accrues to the pharmaceutical companies. Until very recently, we have not been allowed to negotiate drug prices, utilizing our purchasing power with the Medicare, Medicaid, and Veterans Health System programs. In our new national health system, we would negotiate drug prices. Further, there should be some form of profit sharing with the American People when drug discoveries are taken to market after we fund the basic science research that goes into the creation of the new agents.
Thirdly, higher and professional education – nursing, medical, pharmacy, respiratory care, speech pathology, social worker, and so forth – would be viewed as an investment, not as a place to make a profit. We would, in the context of the needs of our health system, federally fund this education, with the student obliged to pay back this educational assistance on a year-for-year basis with service in underserved health areas. Students would therefore no longer exit institutions of higher education and professional schools with significant student debt.
Fourthly, we would, over perhaps a generation, allow for a decrease in the salaries of the highest paid healthcare professionals and administrators. This is not to argue for enforced poverty. Rather, it is to point out that the highest paid healthcare workers should still be well paid, but not exorbitantly so. And it would not just be the highest paid healthcare workers whose salaries would be rationalized. There are, in many institutions, administrators who making $1 million plus yearly; this would be discouraged. I would return us to the era of the administrator that makes a reasonable salary, but does not become a multimillionaire by claiming to be, or being proclaimed as, “Rockstars of Administration” in healthcare.
Finally, we would have to enter into discussions about what services will be covered, how research is funded, how new equipment and hospitals are financed, and so forth. A federal/state/health care worker/patient represented body – something like the British National Institute for Clinical Effectiveness [NICE] – would make suggestions and help direct this process.
^{4:  Health information technology: Improving the efficiency and coordination of healthcare through the widespread adoption of electronic health records and other technological advancements, will this wor Prevention and wellness: Shifting focus from a primarily reactive system to a more proactive one that emphasizes preventive care, early intervention, and promoting healthy lifestyles?}
Improved health information technology will improve our health system. There’s nothing more frustrating than having a patient come into the emergency department with a long medical history that is inaccessible because it’s in another hospital’s electronic medical record (EMR) to which one does not have access. We would have to decide, if not on a single EMR, then at least on a set of standards that would allow inter-operability of the systems. We would have to develop and utilize a novel identification/medical record number/account numbering system, in order to make the system, and the records, interchangeable. This is not the huge challenge it might appear at outset. Such EMR identification systems have been developed and interoperability standards for EMRs can be developed rapidly, if they are not extant.
As stated above, and as you allude to in the question, health is not merely the absence of disease, it is the presence of well-being, both physical and mental. The World Health Organization utilizes such a definition in its description of health. We would need to focus not only on the provision of healthcare services, but also in prevention. This would include work to alleviate food deserts, increase the ability of our citizens to walk in safety on our streets, and the ability of our citizens to access preventive care such as dental care and mental health services. There is much written about “deaths of despair”, that touches on multiple of our ongoing problems: substance use disorder of various kinds, as well as our citizens feeling, and being, extraneous to the working of our country; men and women who have lost their jobs and are disenfranchised. This includes disabled people and the elderly. We speak, often, of the importance of our people, of the individual citizen. However, it’s clear that, often, these are words not matched with action. Thus, we would seek, over time, to develop programs whereby retired people, older people, disabled people, unemployed men and women could feel, and actually be, functional members of our society, whether through volunteering in some fashion, being involved in gardening and/or neighborhood beautification clubs, tutoring, or multiple other interactive opportunities that would help alleviate this problem of despair and the deaths that come with it.
^{5: Medical education and workforce: Addressing shortages and maldistribution of healthcare professionals, as well as incentivizing primary care and other undeserved specialties- Transparency and patient empowerment: Promoting transparency in healthcare costs and quality of care, enabling patients to make informed decisions and actively participate in their own care?}
Shortages in the distribution of healthcare workers would be resolved, utilizing the power of the purse. If national funds are used to educate healthcare workers, and the healthcare workers are obliged to provide service in areas of the country that have shortages on a one-year service per each year funded basis, we can generally direct graduates to areas of need.
We would increase reimbursement/payment for primary care services, including family practice, general internal medicine, OB/GYN, pediatrics and mental health.
Transparency of healthcare costs would be straightforward as the payment system would be nationalized. Prices/reimbursement would no longer be an issue, because everyone would be covered in our national health program – Medicare4All – with no out-of-pocket expenses. There would need to be a commission made up of clinical and administrative leaders to make recommendations as to levels of reimbursement/payment.
Patient empowerment, and interaction with their care is a somewhat more difficult issue to deal with. Yet, when our citizens can choose from a variety of primary care physicians and hospitals and clinics in their area, they will find the practitioner and institution that “feels best” to them. Primary care practitioners would have a smaller patient panel – 500 to 800 patients – than the 1200 to 2000 normally seen today. It is very difficult to provide the individual attention needed for each patient with the large panels. Limiting the size of the clinician’s patient panel would allow them to see the patient as often as needed.
 6:Tort reform: Addressing medical malpractice concerns through measures such as alternative dispute resolution mechanisms and liability reforms to reduce defensive medicine practices?
Tort reform is necessary. It’s also necessary that patients who are harmed by negligent or inappropriate care have an avenue to seek redress. In a national health system, the issue of obtaining ongoing health care for damage occurring while under the care of a healthcare provider would be eliminated. It might be worth discussing whether, in some form, caps on pain and suffering payouts would be appropriate, and whether an alternate dispute resolution mechanism could be utilized by a patient injured while under our care.
It’s unclear how much is spent on defensive medical practices, although there are studies that have looked at this; the amount certainly is not insignificant.
In summary, the ability for the people of the United States to have a high-quality, national health system, funded through progressive taxation, is definitely possible and would improve the living conditions in our country greatly for the vast majority. The only reason this has not occurred over the past 150 years is due to the recalcitrance of those who are enriching themselves in the system as it exists today.
Creating a system that uses as its “North Star” the delivery of high-quality, patient centered, safe care, and that minimizes waste and maximizes patient satisfaction will be a benefit that, once in place, will have people asking: Why did this take so long ?

 
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