Healthcare in America: Costs and Gatekeeping

One of the treasured jewels in America is her healthcare system, so envied by all peoples throughout the world that even many from Socialist systems, such as Canada, England, Germany, France, Spain, Italy, and Scandinavia, where National health insurance systems exist, choose to travel to the United States when they have some important healthcare matter for which they want to obtain the “very best” care. This statement is not some provincial, arrogant American attitudinal statement, but rather a simple statement of fact. Seventy years ago that same statement could have been made by German physicians. But revision of American medical training and the development of the National Institutes of Health, with its encouragement of extraordinary extramural medical research outside of the confines of the National Institutes of Health, resulted in the training of large numbers of exceptionally-informed physicians and the development of innovative thinking and breakthrough developments and treatments throughout the United States in the 1960s and 70s. A variety of factors resulted in ever-increasing costs to the United States government for healthcare of those insured by the United States insurance system for the elderly, Medicare. It was argued (incorrectly in the view of some) that the percentage of the Gross Domestic Product (GDP) expended on healthcare was excessive, and therefore major efforts on two separate fronts where embarked upon to “control” the “growth” of healthcare expenditures: systematic reductions in the amount of Medicare payments for various services; and encouragement of the development and expansion of “managed care” organizations, most particularly in the form of “For Profit” health maintenance organizations (HMOs) and variants of the same. An extraordinary variety of unanticipated results has occurred as a consequence of this experiment, including a degree of pecuniary gate keeping by HMOs and insurance companies which now results, in my opinion, in a progressive “dumbing down” of the level and quality of healthcare available to large numbers Americans today. Additionally, a component of the American healthcare system which was previously extremely important in cutting edge, front line translation of laboratory research into the clinic, the Clinician Scientist, is in jeopardy. Fewer and fewer physicians are choosing to try to live the life both of the active clinician and of the laboratory researcher, and those who have made that line of work their living for the past 20 years are finding it increasingly difficult to “walk both sides of the street”. And instead of realizing that a treasured commodity has been unwisely tampered with, some would have us believe that the failure of the HMO gatekeeping system is evidence that the only solution to the current healthcare system morass is a nationalized healthcare service. Indeed, it is my understanding that one of the people most involved in the original development of Health Maintenance Organizations was so appalled at the gatekeeping substandard quality of care that he personally received in the not-too-distant past, that he now rails against the HMO system and advocates a nationalized healthcare insurance. I predict that he and others of like mind will likely prevail in the end, for a variety of reasons, including the misguided view that doctors are a bunch of greedy elitists who need to have their incomes reduced anyway. I also predict that if healthcare and healthcare insurance continues in that “dumbing down” sort of trend, we will end with the unenviable national health circumstance that all of the aforementioned Socialized countries currently experience: long waiting times for elective surgical procedures such as cataract operations; extremely restrictive access to cutting edge, advanced therapy; denial of various services and procedures which we here in America take for granted; a steady reduction in the innovations and discoveries made by members of the American medical community.

It is a complex problem without easy answers, and those who suggest that the “easy answer” is the nationalization of healthcare, in my view, have it exactly backwards and exactly wrong.

Download PDF C. Stephen Foster, M.D.
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