Dr. Michael Fine: What’s crazy about health care and the presidential election

Before I start talking about the current presidential campaign, I thought I’d disclose my biases. I’m an independent with complicated political views: fiscally conservative, small government oriented, socially progressive but not woke.  I don’t love our choice this year, which seems to me to be the choice between Julius Adolph PT Trump and Tweedle Dum and Tweedle Dee – the current VP seems smart and capable but is running a weak-wristed campaign in which she isn’t really saying much beyond don’t vote for the other guy.

All that said, I’m particularly disappointed in what both parties are saying and thinking about health care and health policy.  Trump has “concepts” about health care, which seem like a scary moment, given the source and where many of his “concepts” lead him. Harris can’t seem to get much beyond defending the Affordable Care Act and the tiny progress made on contracting for drug purchases under Medicare.  She echoes the usual Democratic pablum about how expanding access to health insurance or tinkering with Medicare will somehow fix the huge health care mess, even though a decade and a half of experience under the Affordable Care Act taught us that expanding access to health insurance was a good thing, but carried with it cost increases, the enrichment of insurance companies and hospitals, and made no progress on controlling costs or improving public health outcomes.  Earth to Democrats:  we have a real health care crisis out there – not enough doctors and other health professionals, inadequate access to the services that exist, and the wrong services available at the wrong times and at outrageous prices.  So, Kamala and Tim, your usual health policy ideas ain’t cutting it, despite what the pundits from Yale, Harvard, UPenn, Johns Hopkins and Stanford are writing about and saying at their zooms and conferences.  They don’t get it.  Neither, apparently, do you or the Donald.

But there is a fix hovering around out there. 

The fix is simple. We need a Marshall Plan, a New Deal, or a Moonshot for Health Care – a huge national effort to train a zillion new doctors, nurse practitioners and other health care workers, a way to take students from all our communities and turn them into the health professionals we need to provide primary care to every neighborhood and community,  at the same time as provide enough health professionals for hospitals, specialty practices and nursing homes. 

Most of the dysfunction in health care, most of the excess cost and some of the poor public health in the US, can be traced back to one simple problem: we just don’t have enough health professionals to care for the whole population.  The primary care shortage means that people can’t be seen near home when they are sick, so they use/overuse emergency departments and urgent care centers, while creates opportunities for investors to profit by selling those people more expensive (and often unnecessary) services.  The shortage of specialists means long wait times and crazy prices, because we’ve created functional monopolies for specialty services.

 There are ten thousand things we need to do at once to fix this mess – shorten medical school, open a zillion new medical schools and expand their classes, multiple the number of primary care residencies by a factor of four, standardize the quality and increase the number of nurse-practitioner training programs, create nurse practitioner residencies, create scholarship programs (with obligations to practice primary care locally) so everyone committing to primary care can get trained for free, and completely change how primary care clinicians and practices are trained.  And it all needs to happen at once, which means we need to roll up our sleeves and concentrate on fixing this problem.  The Moonshot approach, a great national effort, is something we do once in a generation to get big stuff done – winning World War Two, putting a man on the moon in fact, and trying to reverse the generational impact of slavery.  We’re a little dysfunctional right now.  But when Americans put our minds and our backs into fixing a problem together, we almost always get it done.

Crisis is opportunity.  The medical marketplace mess is a problem that impacts everyone living in the US, in every American neighborhood and community.  And everyone has kids who want to become doctors. So a big proposal, that would really fix a real American problem, might stir the imaginations of everyone in the US who is disappointed by this election, by its candidates and its lack of substance and dignity.

A chicken in every pot!  A primary care practice in every community! All the kids who want to go to medical school or nurse practitioner school and are qualified get to go but can’t get in because there aren’t enough places! Students from all our communities, practicing in their communities!  Communities who can see their kids grow up and serve the communities from which they came!

Earth to politics:  Propose the Moonshot for Healthcare and fix this mess!  It’s crazy to hope that the political process can fix anything, but it’s crazier by far to ask us to keep living with the disaster we’ve got.