Universal Healthcare: It’s Time for a Better, Cheaper Way

Universal Healthcare: It’s Time for a Better, Cheaper Way

We hear a lot of rhetoric about universal healthcare, one of the most popular proposals (which I support) being Medicare for All. But what does universal healthcare really mean for the American people?

The simplest definition is a system of healthcare for all paid for with public funds. Providers (which means doctors, hospitals, and everyone else who renders health care to patients within the system) provide the care, and it is paid for with money that comes from taxes.

In its pure form, then, there is no health insurance, there are no bills, and there are no deductibles or copays. You, as a human being in need of health care, consult me, a physician; I take care of you; no money changes hands; the government pays me, using public dollars (tax revenues) for what I do.

Depending on how you view the government, the thought of a government-run health care system may hold more or less (maybe even zero) appeal for you. But in its most basic sense, the essence of what I’m writing about here is public financing of health care, which can occur within but does not require a healthcare system that is operated by the government.

So, for example, the Medicare and Medicaid systems are financed with public dollars, and the government operates the Veterans Health Administration. Right there you can see how a broad spectrum of opinion might be generated on the idea of the government doing things. The VA has its admirers and critics – recently mostly critics, because of failings in looking after the health care needs of veterans, and Medicaid has more critics than there are crystals of salt in the ocean, it seems, while Medicare gets pretty high satisfaction ratings from seniors.

Aside from fundamental mistrust of Big Government by some, there is concern about Big Waste by the feds. Well, Medicare is, by any measure, less wasteful than just about any private health insurance enterprise, in that it spends a higher proportion of every dollar on health care, with less going toward administration and zero going to profit. The role, or lack thereof, of profit in the health care system and the way we finance it is an essential part of the consideration of “socialized medicine.” That could be the subject of a very long essay all by itself, but if you believe the profit motive is bad in this context, I submit that universal healthcare is the only way to eliminate it.

Some doctors are suspicious of a system that would essentially make them government employees – and they aren’t the only ones. Many of us like to quote, derisively, the imaginary expression, “I’m from the government, and I’m here to help you,” as if those two things couldn’t possibly go together, and anyone who says such a thing should be viewed with a mixture of amusement and paranoia.

But we don’t have a problem with firefighters being government employees. Or the Coast Guard. Or air traffic controllers. Or any number of other people we trust with our lives. So we certainly shouldn’t assume that doctors who are government employees would be in any way inferior. The patients in the VA system do not, as a rule, have a problem with the quality of the doctors but with the system that lacks the capacity to care for them.

As a nation, we recognize that shortfall, and we are demanding it is remedied. If we had a system for everyone that had inadequate capacity, how quickly do you think we would demand – and get – action to solve that?

Many who deride socialized medicine look to the United Kingdom’s National Health Service and say people wait weeks or months for elective surgery, and Americans won’t tolerate that. Three things you should know about that: First, Americans with no health insurance don’t wait weeks or months for elective surgery. They wait forever. And that is unacceptable in the wealthiest nation in the history of the world.

Second, the satisfaction of the Brits with the NHS is higher than our satisfaction with our non-system, regardless of any of the (exaggerated) claims about their waits for elective surgery.

Third, per capita spending on health care in the UK is half what it is in the U.S. I am entirely unwilling to believe we couldn’t create a system that covers everyone with what we’re spending, with high quality and no long waits for anything.

[What we have now, instead, covers 85 percent of our population, many with woefully inadequate health insurance that has ridiculously high copays and deductibles, and leaves 15 percent.

If you think we can’t do that, I must ask you why.

Two possible answers come immediately to mind. The first is that we are a lot dumber than the Brits, and although that is possible, I don’t think so. The second is that we cannot do that without eliminating all of the waste associated with having a for-profit health insurance industry, in which many dollars intended to be spent on healthcare are, instead, spent on administration (twice what the government spends for Medicare administration), and profit, and seven-figure executive salaries.

If you guessed that the second possibility might indeed be a big part of the problem, go to the head of the class.

I must now ask you to consider a simple question: If you work for a living and have employment-based health insurance, it’s called a benefit of employment. That means you worked for it. You earned it. And every dollar that you earned that is spent on health insurance premiums is, in principle, a dollar that should be spent on health care.

Looked at the other way, every such dollar that is not spent on healthcare is a dollar wasted. So, every dollar that a health insurance company diverts to profit, to eye-popping executive salaries, and excessive administrative costs is a dollar wasted. Looked at even less charitably, every such dollar spent on those other things is a dollar stolen from you.

The solution? Eliminate the health insurance industry. If we do that, we must have a new way to finance health care. What would that be? Re-read the first two paragraphs. And now you know the answer to the question posed in the title of this essay.

Utopia or dystopia? Neither. It is, plainly and simply, what we must seriously consider if we hope to have a system for financing and providing health care that works for everyone, rather than the absurdly fragmented and wasteful non-system we have now.

A Simple Solution to Gun Control?

A Simple Solution to Gun Control?

When I read online commentary on gun control measures, I see opinion divided into two camps: Guns are the problem. Or mental illness is the problem. American gun violence is a complex matter, and the availability of guns and the prevalence of mental illness are both important factors.

Are we going to do something to reduce dramatically the availability of guns? All the evidence points to no. We have more firearms in the USA than we have people. We had a ban on semiautomatic rifles for 10 years, but it had little effect on supply, and it sunset without evident effect on crime, partly because these weapons are used in a tiny fraction of incidents in which people are killed with guns, even though they are used in a sizable proportion of mass shootings.  We may have another ban on these weapons as the public demand to “do something” escalates.  

Or we may not.

So, I have a simple idea that might make a small contribution. Small contributions have the disadvantage of being small, but sometimes they have the advantage of being workable, so consider this one in that light.

In the spirit of full disclosure, there are three things I should tell you about myself. First, I am a doctor specializing in emergency medicine, with a longstanding interest in public health, and I’ve read a lot about the public health perspective on gun violence. Second, I am a gun owner, and I have read a lot about American gun culture. I can tell you how gun owners think and feel, and I can explain the positions of the NRA and the other gun-rights advocacy groups that take an even harder line (believe it or not). Third, I am running for state Senate, so I think a lot about our current public health problems, including social problems, from the “there-ought-to-be-a-law” viewpoint. 

If a voter asks me what I will do, if elected, about gun violence, “I don’t know” is not an acceptable answer.

We live in Pennsylvania. In PA, doctors have a legal obligation to report to the Department of Transportation drivers who have medical problems that may cause them to have episodes of loss of consciousness that would be dangerous if they happen while driving. This affects mostly people with seizures, but diabetics with repeated episodes of low blood sugar, people with fainting spells of various causes, and alcoholics and other drug addicts who lose control of a vehicle because of an overdose are all reportable.

So how about this?  Why not ask a doctor who encounters a patient with behavioral problems such that, in the physician’s judgment, this person should not have access to firearms, to make a similar report to an appropriate government agency?

How would that work? Here are a few essential points.

  1. Doctors would need guidelines. So form a panel of experts to create them. What are the signs a doctor can recognize that mean a person is potentially dangerous in ways relevant to having access to guns? Require all licensed physicians to learn these guidelines. State medical boards already micromanage our continuing education, like requiring all licensed physicians to take two or three hours of online education about opioid prescribing and addiction, or child abuse, so this would be easy to do.
  2. Reporting in good faith would be legally protected.
  3. A person who is reported would be investigated regarding whether s/he should have the right to possess firearms restricted. There would be built-in due process involving appropriate parts of our legal system, with the right to appeal and the right to petition to have gun rights restored.

Would this identify everyone who is emotionally unstable and shouldn’t have guns? Of course not.  But what do we do now? The people who are disqualified are those hospitalized involuntarily because of mental illness, and those who are adjudicated mentally incompetent. That is a small portion of the population of people who shouldn’t have guns because they are a potential danger to themselves or others.  

And the expansion of the “pool” adopted during the Obama Administration, and reversed by Trump, that would have added people judged by the Social Security Administration as incapable of managing their affairs (financially) was vigorously opposed by both the NRA and the ACLU.  That should catch your eye, because the ACLU does not recognize a Second Amendment individual right, even after the Supreme Court explicitly did.

We need creative solutions. Lots of them. And they have to be solutions that can get substantial buy-in from interested parties on various sides of the issue. This is one. I will do my best, if I am elected to the Pennsylvania Senate, to fashion more that I think can be enacted in an American society that is starkly polarized on this issue.

The Heroin Epidemic’s Historical Roots

The Heroin Epidemic’s Historical Roots

Pardon me for jolting you out of the Third Millennium, but I want to take you back to the early 1800s, when Thomas Jefferson was president of the United States and Friedrich Wilhelm Adam Sertürner was a pharmacist’s apprentice in Paderborn (then part of Prussia).

Sertürner purified one of the active alkaloids from the opium poppy and named it morphine, after the Greek god of sleep and dreams, Morpheus. Morphine was given that name because of its propensity for inducing drowsiness. It also stimulates receptors in the human central nervous system involved in the perception of pain, and so it has analgesic effects. And it can elevate mood – produce euphoria. Thus morphine – and later its many derivatives and congeners – was added to the list of things we now called “mood-altering substances.”

Friedrich Wilhelm Adam Sertürner

Morphine was brought to market by Merck, the German chemical company, in 1827. Then in 1874 Charles Romley Alder Wright, a British chemist and physicist, was tinkering with morphine and added two acetyl groups to the molecule, creating diacetylmorphine.

When injected intravenously diacetylmorphine has a more rapid onset of action than morphine and is more potent (a smaller dose is required to produce an effect of the same magnitude).

Heinrich Dreser, a chemist working for Bayer (another German chemical company) continued testing diacetylmorphine, and Bayer brought the drug to market in 1888 as a cough suppressant and pain reliever under the trade name Heroin. Twenty-five years later, recognizing its potential for causing addiction, Bayer withdrew it from the market.

Most Americans think of heroin as an illegal drug because it has that status in the United States. By contrast, it is used medicinally in the United Kingdom and is superior to some other agents because of its rapidity of onset of action and its more favorable side effect profile.

In the U.S. it is on Schedule I of the Drug Enforcement Administration’s list of controlled substances. Schedule I is supposed to be reserved for drugs that are considered dangerous and have no recognized, legitimate medical use. As heroin does not meet the second criterion (except by arbitrary and unscientific edict), it does not belong on Schedule I.

Since the 19th Century we have developed many synthetic derivatives of the substances isolated from the opium poppy, and we call them, collectively, opioids. Although at one time such substances could be purchased without a prescription in the US, at present only codeine (the other active alkaloid from the opium poppy) can be obtained without a prescription, and only in certain formulations, from some pharmacies, in about a dozen states.

Given that people have been cultivating opium for at least 5,000 years, it is interesting to contemplate the fact that some mood-altering substances humans have derived from plants (opium, coca) are considered to have such high potential for abuse and addiction that they are very strictly controlled, while others (alcohol by fermentation of the sugars in plants, and tobacco) are regulated but easy to purchase legally. Addiction to opioids and cocaine and addiction to alcohol and nicotine have many similarities, and all of these substances can be damaging to health and lethal in overdose.

We experimented with the prohibition of ethanol in the U.S., and that is viewed by most as having been a spectacularly unsuccessful experiment.

And that brings us into the 20th Century when we decided that opioids should be available only by prescription. This means that if you need the most effective of the pain relievers, you must consult a physician. That is obviously somewhat arbitrary. Stressful day at work? If you go home and have a glass or two of wine to relax and unwind, that is considered no problem and meets a common definition of moderate drinking. If instead, you wanted to have 5 or 10 mg of oxycodone, that is considered a very serious problem.

Sociologists and criminologists use the term “social problems” to describe a vast array of societal ills, and misuse of opioids is, in my view, a social problem. Many things that are social problems cross the very blurred lines and are also viewed as medical problems, and of course, misuse of mood-altering substances can be regarded as a medical problem. But in its strictest sense, it is only the complications of the misuse that are medical problems: overdose, infectious complications of injection drug use, etc.

In my specialty (emergency medicine) we find ourselves addressing social problems a great deal of the time, both because the profession has “medicalized” many social and behavioral problems and because the emergency department is often the place to which people turn for help when they have no idea what to do.

bob solomon heroin

Abuse of, and addiction to, opium has been around for millennia. Blame it on something that, in pharmacology, is called the “fallacy of the specific.”

The fallacy of the specific means that one should never assume – because the assumption will usually be wrong – that a drug will do one thing, its intended effect. In this case, opioids relieve pain, but they also have effects on mood. Those latter effects get some people into trouble, because they like that feeling, and they may start using a drug for relief of pain and then use it partly to relieve pain and partly to feel good more generally, and before you know it they are using it as much for mood elevation as for pain relief, or even entirely for mood elevation, without even realizing that is happening. And then they may find themselves using it to keep from getting symptoms of withdrawal from the drug. A person may find anything from a general unease to restlessness, cramps, vomiting, diarrhea, and sweats occurring because the nervous system has gotten used to the drug, and now it’s not being provided. Then the addict is using the drug not to feel good but to keep from feeling terrible.

Legal acquisition of opioids requires consultation with a physician, and a prescription and many addicts start with prescribed opioids and end up using far too much of them and engaging in all sorts of deceptive behaviors to get them from insufficiently wary (or blatantly unethical) doctors, or they switch to illicit sources and start snorting, smoking, or injecting heroin.

The problem of abuse of and addiction to mood-altering substances has been part of the human condition for thousands of years, and modern medicine has been around for about a century. But why?

Human existence is miserable. Not for everyone, but for a sizable minority of us. And that’s what mood-altering substances are all about. We smoke tobacco; we drink beer, wine, and liquor; and we use opioids and other potentially dangerous drugs like cocaine – all to find a temporary escape from the misery, or at least drudgery, of human existence.

At its foundation, this is more a social problem than a medical problem. My colleagues and I will do all we can to help to solve it. If given the opportunity to serve in the Pennsylvania Senate, I can use that experience to push legislation and initiatives designed to stem the opioid epidemic.