The Winners and Losers of Our Health Care System


Bob_circleA 9-year-old son having trouble breathing in the middle of the night. A husband who has a seizure. A teenage daughter who shuts herself in a room after cutting herself and threatening to kill herself. A diabetic whose glucose level is out of control. People and their families confront health problems like these every day, regardless of where they live and what kind of health insurance, if any, they have. Yet where people live and whether they can afford care makes all the difference in how they access the services they need and the outcomes they desire. Lately, there’s been talk about whether or not hospitals, as they currently exist, are still necessary in today’s changing health care environment. I think it’s worth taking a closer look at the value of hospitals and how the system ties into the health safety net and ensuring reasonable access to care for various populations.

The complex growth and evolution of the U.S. health system has been characterized in many ways, recently from the perspective that ever-rising costs are a tapeworm feeding off the system. Administrative expenses are a big piece of total costs. Overall, the health care industry employs more than seven times as many employees to collect payments as other service industries. Given the widely recognized problems with our system, it is reasonable to look at several recent news stories that highlight changes underway in American hospitals, which are key actors in providing care.

Headlines are revealing. The first article, titled “Are Hospitals Becoming Obsolete?” makes no mention of the main reason we have fewer hospitals today. Nor is there any reference to the fact that hospitals provide emergency treatment, a crucial component of the health safety net for people with health issues like those listed above. In other words, the perspective of how changes to hospitals will threaten the health of those most in need of a strong health safety net is absent. The next article does not mention people who are under-insured or uninsured either, but the subtitle nails what’s driving change (emphasis mine): “What the Hospitals of the Future Look Like: Driven by economics, the sprawling institutions we know are radically changing – becoming smaller, more digital, or disappearing completely. The result should be cheaper and better care.”

These two articles, along with others that highlight the growth of alternative settings like ambulatory surgical centers and urgent care centers, capture the shifting type and location of health service organizations responding to payment incentives. Many of these alternative settings are for-profit businesses, while most hospitals are not. The locations of such centers target patients who can afford the services, not those who need the services. The de facto exclusion of the increasing number of people who cannot afford services is seldom acknowledged, although it is becoming a central health care issue as the proportion of Americans who cannot afford care increases. The irony for our policymakers responsible for thinking about care for all Americans is that the institutional infrastructure that dominates the U.S. health system has responded effectively to perverse payment incentives for a half century. Ultimately this has systematically created barriers to care for low- and moderate-income Americans, and these obstacles are only increasing.

We have an unfair system. The real question is, how do we change the extent to which our health systems are designed and organized for the benefit of the businesses, institutions, and professionals within it rather than for the population served? And this population should be all of us, not just those who can pay. If we can’t begin to revise the current direction, more and more Americans will have less access to care, and the health safety net will become even more fragile. Those most in need shouldn’t have to decide if their health issues will be deemed not an emergency after the fact. They shouldn’t have to forego care because of the fear of expenses, and they shouldn’t be denied needed care because of where they live or their income. Our health care system should care for all of us, and do it equitably.