Sarai was 25 years old when she died of Wilson’s disease, an inherited disorder that causes liver failure. A liver transplant could have cured her, but she was uninsured and was denied an appointment at two prominent Chicago transplant hospitals, including my own. Sarai’s plight was brought to my attention when a local religious group held a hunger strike advocating transplant access for Sarai and other uninsured patients. When she died, her congregation marched seven miles, holding her photograph and lugging coffins emblazoned with her name, to launch a sit-in in front of Northwestern University Hospital. Her death certificate named liver disease as her cause of death, but that’s not true. The real cause was inequality. If the United States had a Medicare-for-all health insurance system, she might have been saved.
In nearly 40 years as a doctor, I witnessed time and again how inequality kills. Those without health insurance, such as Sarai (there are almost 30 million in the country), often cannot access the most basic care, let alone complex specialty care. But the problem is more serious than a simple lack of health insurance. What insurance card you hold can literally be a matter of life and death.
Consider how our current multi-payer health insurance system affects hospitals, clinics and patients. I have practiced at three hospitals along a two-mile strip of Ogden Avenue in Chicago. I spent 17 years at Cook County Hospital, now the John H. Stroger Jr. Hospital of Cook County, rising from intern to chief of general medicine. When I practiced at Cook County Hospital, it was largely a hospital for the uninsured. Despite many improvements, largely because of Medicaid expansion under the Affordable Care Act, many services, such as screening colonoscopies and hip replacements, are still beyond reach for patients and their doctors. I spent a decade at Mount Sinai Hospital, a not-for-profit hospital for the poor in North Lawndale, a neighborhood of concentrated poverty in Chicago. Sinai cares for a mostly minority population that is mostly uninsured or on Medicaid. In my 27 years at these two safety-net hospitals, not one of my patients received an organ or bone marrow transplant. Yet the organs that fed the transplant centers across the region came from the dying patients in these hospitals. Our patients — the poorest of the poor — gave, but they never received.
For the past 12 years, I have practiced at Rush University Medical Center, an academic medical center replete with the finest care biomedicine can offer. Because my hospital serves a variety of patients with different insurance types — many with private insurance, Medicare or Medicaid, and some uninsured — it is able to afford and offer a vast array of services. But those with the wrong insurance card cannot access the care at my hospital. In contrast, hospitals that only serve the poor and uninsured, such as my two prior hospitals, are more limited in their scope because the payment systems for the uninsured and those on Medicaid constrain their ability to buy new equipment or invest as they need. Compared with Cook County and Mount Sinai, Rush felt like a different planet my patients and I had landed on, where previously out-of-reach medical care was now available.
I realized that all the doctors and nurses in the world could not cure health-care inequity if the insurance system itself was the problem.
I call my experience on Ogden Avenue “one street, two worlds” because that short stretch of asphalt separates two very different worlds of health and health care: one for those institutions who have patients with better health insurance, and one for those for hospitals who largely serve patients with limited or no insurance.
My experiences also reflect the observations of Princeton economist Angus Deaton, who noted that the United States virtually has an apartheid health-care system. As structural racism has concentrated black and brown poverty into certain Zip codes, the hospitals and clinics serving minority neighborhoods often face severe resource challenges compared with those serving affluent neighborhoods of concentrated advantage. This inequity is only magnified by the way health insurance has been distributed across America. But it not just the poorest who are at risk. Our current multi-payer for-profit health insurance system perpetuates premature death by putting many people at an extreme disadvantage when it comes to affording care. Those who have better health insurance policies can access better care. However, even patients with insurance cards face skyrocketing co-pays, deductibles and pharmaceutical prices that keep them from seeking care. Last year, 27 percent of Americans said they had postponed or avoided getting care they needed because of the cost; 23 percent said they had skipped a recommended test or treatment due to cost; and 21 percent said they had chosen not to fill prescriptions for medication because they couldn’t afford it.
Death rates tell the same story. Since 1980, there have been dramatic gains in life expectancy for the top 20 percent of U.S. earners. At the same time, the poorest 20 percent have seen their life expectancy plummet. While access to health insurance is not the only cause, it certainly contributes to the life expectancy gap. In Canada, with its single-payer health insurance, the life expectancy gap between the rich and the poor narrowed during the same period.
There are three fundamental problems with the patchwork U.S. health insurance landscape that a Medicare-for-all system would resolve. First, our current reliance on for-profit insurance forces working families to pay increasingly burdensome prices for health services and prescription drugs. The Affordable Care Act was never a viable solution, because it relies on the for-profit insurance industry, which is geared to maximize shareholder returns rather than high-quality, low-cost care for all. Meanwhile, taxpayers have funneled billions of dollars to support premiums for individuals and subsidies for insurance companies. Second, Medicaid, the health insurance program for the poor, shares many of these same flaws. The quality of the program varies by state and is a major burden on state budgets. Finally, the current system is inequitable for low-income or uninsured patients. Every day, people such as Sarai die when they could have been saved.
The best solution is a national solution; one that has been implemented by nearly every other developed nation. Medicare, the popular insurance program for those over 65 and people with disabilities, has a 90 percent satisfaction rate. Under a Medicare-for-all program, every worker and business in America would pay into the system through a combination of payroll and other taxes and fees, just as we pay taxes and fees for schools, water and the military. There would be no complex health insurance payments to navigate, no prohibitive co-pays and deductibles, no corporate welfare to boost insurance company profits. Untangling health care from employment would not only free workers to change jobs or start new businesses, but would also eliminate the largest and most stealthy tax loophole in the U.S. tax code: the $250 billion annual tax-free subsidy of employer-based health insurance.
Medicare for all would solve the problems of health-care access for the poor and rural. Such a system would allow hospitals and clinics to survive at a time when many of them — often the largest employers in their communities — are threatened with extinction. Moreover, it creates the opportunity for America to eliminate health inequities and improve life expectancy because, by design, everyone will be in and no one will be left out.
As a doctor, I have a moral obligation to care for patients regardless of their insurance status or ability to pay. But America’s fragmented, for-profit health system forces doctors to violate their Hippocratic oath, the moral contract requiring us to treat health as a basic human right. I speak for many American physicians when I say I am sick and tired of a health insurance system that harms our patients, many of whom are sick and tired themselves.
The right to health care in America is not an issue of the left or the right. It’s a matter of right and wrong. Winston Churchill reportedly said, “You can always count on the Americans to do the right thing … after they have tried everything else.” Today, Sen. Bernie Sanders (I-Vt.) will introduce a bill in the Senate that will provide a path forward for Medicare for all. Let’s do the right thing. We have tried everything else.