乌鸦传媒

In part 2 of this exclusive video interview, Jeremy Faust, MD, editor-in-chief of 乌鸦传媒, and Jerome Adams, MD, MPH, discuss Adams's recent emergency department (ED) bill and why the U.S. spends more on healthcare than other developed countries.

Adams was the 20th U.S. Surgeon General and is currently the director of health equity at Purdue University in West Lafayette, Indiana. In his conversations with Faust, they previously discussed the contribution of the medical-legal environment.

The following is a transcript of their remarks:

Faust: Let's talk about the prices, because the prices are so -- as you say in your piece -- the transparency is not there.

But I also want to take the devil's advocate [position] and say that there's a reason why a bagel costs 50 cents at one place and it costs $3 on Madison Avenue in Manhattan. It's because of rent, and it's also because when you walk into the bagel shop in Manhattan, you're not just paying for the everything bagel that you chose. You're paying for the option of 50 other bagels you didn't buy.

The ER functions that way. We are ready for all things all the time, and so a $40 metabolic panel suddenly is actually $400 because we're really covering that. Does that make any sense?

Adams: No, it absolutely makes sense, except when you realize that people get the exact same care in every other developed country in the world, and it is nowhere near this cost.

I actually don't think that's the root problem. I think the root problem, and I talk about it in the article, is going back to EMTALA [Emergency Medical Treatment and Active Labor Act] which was passed under Reagan in a Republican administration, which first really accelerated cost shifting because emergency departments and healthcare systems were told, "You've got to take care of everyone who comes in." Which I think is the right thing to do with an emergency situation until you're assured that they're stabilized, but there was no mechanism to pay for it.

It really accelerated, some of this perverse cost-shifting that was going on. So I'm not paying for the 50 other bagels I didn't buy, I'm paying for the 500 other people who came in who got bagels and didn't have to pay for them.

That's really what accelerated the cost. Then the Affordable Care Act also said that we can keep our kids on our insurance until they're 25, which I'm happy about because I've got a 20-year-old and a 19-year-old. They're happy about it. It said that we have to provide additional care, which I actually agree with, but it didn't provide a mechanism to fund institutions for providing that care in most cases.

So both Republicans and Democrats forced these unfunded mandates on healthcare institutions, and that caused this perverse cost shifting.

What we saw after the Affordable Care Act was that most employer-provided health insurance shifted over to high-deductible health plans, which we can dig into if you want to, but that's another part of my scenario that really resulted in me getting this $5,000 bill, which most Americans couldn't afford.

Faust: Yeah. I really want to echo what you said about EMTALA and the Affordable Care Act. Both of these things expand access, which is really, really good. But also both of these things have a cost and haven't always been paid for, or at least we kick the can down the road.

In the case of EMTALA, what happens is, as you said and this resonates, that half of patients in the ER can't afford that care. So it's the other half who are being overcharged to pay for that so that the business model stays intact. In the case of the Affordable Care Act, it's that the cost of health insurance premiums and how much people are paying out of pocket every year has gone up to make that up.

And I'll never forget this, when the Affordable Care Act was being debated in D.C. and I was in medical school, I asked somebody who was working on this -- they were actually at HHS -- and I said, "Wait, what's going to happen when this gets too expensive? Aren't healthcare costs just going to become so high that people can't pay them?" And this expert's answer was, "Oh, don't worry. It pays for itself." And I said, "Oh, boy, that's not going to work. But hopefully, we'll be able to fix it as it comes." I think that your example is a situation where we haven't.

Adams: But can I hit on one more quick point? Because it's important at this part of the story to go back to the point that I raised in the article and that you highlighted about transparency also.

Whether you're talking about the Affordable Care Act, whether you're talking about high-deductible health plans, we like to pretend that healthcare is operating as a free market in this country. If I want to go and buy a car, if I want to go and buy a washing machine, my wife and I are going to go look for a new mattress this weekend, you don't walk into the store and there's no price on anything and they say, "Eh, don't worry about it. Don't worry about it. We'll give you what you need and then we'll send you the bill in 6 weeks." Right? This in no way, shape, or form a free-market type of approach, but that's healthcare.

And to your point, I would gladly, if I was in that emergency room and been told that I was going to get a $5,000 bill, I would've exercised my right to say, "I'm going to sign out AMA [against medical advice]. I'll relieve you of any responsibility. I'm signing out AMA because I know this is dehydration at this point, and I don't need to stay in here and get a $5,000 bill." So, the lack of transparency is a big problem here.

I say it kind of tongue-in-cheek in the article, but we actually [do this] with emergency medical care for our pets. I've been through this with my pets twice; they come in, they do a quick triage, they say, "Okay, it's going to cost you somewhere between this amount and this amount. Do you want this care?" We've actually figured it out for pets a long time ago.

With AI and with electronic medical records, there's no reason that we couldn't come up with better systems to at least give people an approximate cost for their care if we're going to continue to pretend that this is a free market.

Faust: Yeah. And a lot of times patients will ask me, not often but a lot of times -- some of the time, "What's this going to cost?" I say to them, truthfully, "I don't know." But the other thing I say to them truthfully is, "I actually don't want to know. Because as an ER doctor looking at you, I don't want dollars and cents to actually cloud my judgment of what I think you need." And so this becomes a circular reasoning of: I don't want to tell you because I don't know, because I want to do the right thing for you, and therefore you don't have the option to make a choice. These are fighting against each other.

Adams: Yeah, they are. And you and I have known each other for a long time, and I greatly respect how you look at things and I appreciate that concern.

What I would say is that the flip side of that concern that you have about not providing the best care for that individual is that you don't see the 10 individuals who won't even come into the emergency department because they're scared of the cost. So they're not getting any care at all. They're not getting even one iota of your great care because they're scared that if they come in, they're going to get hit with a $10,000 bill that they can't afford.

So I think we need to understand that there are many people who are denying themselves access to high-quality care, even with the Affordable Care Act, because they're terrified of these surprise bills that they often end up with.

Faust: You're 100% correct, and I know this because I used to work in a city hospital where people would come in only when they had to. And the thought in your mind was, why didn't you come in like a week ago? And the answer was, they weren't sick enough to risk all that. Or even sadder, they'd say they thought that I was going to call immigration on them because they're not documented. I have seen this, and it's tragic and it's a situation that I think the whole system would benefit from an overhaul.

I wanted to get here later, but since the conversation has led to it now, people in the comments section of your article did say, "Well, wouldn't Bernie Sanders' approach be better? Wouldn't single-payer be the way?" And I always answer this question by saying, "I don't know. I know it works in other countries, but I'm not sure this country is set up for that." What do you think about that?

Adams: Well, I think that that is one way forward, and we've slowly gone in that direction with Medicaid expansion. That said, [there are] a couple things we have to remember.

One of the most important things we have to remember is that healthcare is 20% of our GDP in this country. Most people in the medical world think about that in terms of waste, but it's 20% of the profit that we generate in this country. We built a system -- W. Edwards Deming said that every system is perfectly designed to deliver exactly the results that it delivers, and I think we have to understand that our economic success as a nation is predicated on this market-based healthcare delivery system.

So whether you want the Bernie Sanders system or not, you can't ignore the fact that if you shift there, you have to figure out how you make up for this industry that's now become 20% of our GDP. Those are real jobs in peoples' communities. Those are real institutions. That's number one.

But I think also important to understand is -- and I do a lot of work in other countries, with the Swiss government and the Irish government, and I look at their systems. You also can't go to a system where you're giving universal access to healthcare and single-payer until you can agree upon what that actually means.

A real example: you go to Canada or the U.K. right now, and you'll have no shortage of people who will tell you that they're waiting 6 to 8 months for their elective surgery. In the United States, if you take someone who comes in to their doctor in pain or with a diagnosis and they get told that they're going to have to wait 6 to 8 months for their elective surgery, they will lose their minds and they'll be on the phone with their lawyer or their local news station right away.

We have a different expectation for what universal access to healthcare and a single-payer system would look like here versus other countries. Until we're ready to have a very mature and nuanced conversation about that and about the fact that we can do this, but if we do this it means that you're not going to be able to get what you want when you want just because that's the cultural expectation here. I think there's a lot of nuance here.

So at the end of the day, to answer your question, I don't think that we are quite ready as a nation to really go there even though it sounds good. But I also think that we don't have to. Switzerland, for instance, has a system where they provide access to a certain level of care for everyone in the country. If you want more, you can buy it off of the market.

I think there are hybrid systems that we can and should be thinking about that are predicated on giving people a baseline level of care, guaranteed, that do work and still allow a free market to exist.

Faust: You're hitting on something very fundamental, which is that expanded access actually means expanded demand artificially. It means that the demand that's already there will be met. So it's not like, "Oh, there's free stuff. Let's go get free stuff." It's, "Oh, it's not going to break my whole entire financial life. Let me get this mole looked at because it might be cancer."

I've been living that here in Massachusetts where we've had what you call Romneycare or MassHealth for a long time, which really was the underpinning of the Affordable Care Act. And I'll tell you, we are starting to see exactly what you're talking about: people who are waiting months and months and months for "elective procedures." On paper, you and I would say it is elective, but if you ask the patient in pain, "How elective is this?" The answer is: "Not very." So I think that your point is very well taken.

Adams: Can I hit one more point? I know we've got a lot to cover and I love this because there's a lot to unpack in this conversation.

I am currently the director of health equity at Purdue University. I have a master's degree in public health in addition to my MD, and I feel like one of the other problems is that we tend to frame every issue when it comes to health in terms of diagnosis and treatment instead of in terms of prevention and building healthy communities. Fewer people would need knee surgeries if we actually didn't have 60% to 70% of our country obese. We would need less heart surgery if we could actually prevent hypertension with proper diet and nutrition upfront.

I say that and I think it's incredibly important because we're in a hole and we're continuing to dig every time we look at this in terms of needing to provide care for people when they're sick to be able to get diagnosed and treated. Every dollar we spend there is the equivalent of spending far more money on the front end.

There's the old saying, "an ounce of prevention is worth a pound of cure." If we would focus more on building healthy communities where people can exercise, where they can eat well, where they aren't in environments that are bad for their mental health and encourage substance misuse, I think that's one of the problems we have here.

When you compare us, again, to other developed nations, particularly European nations, people often say that we spend more per capita on healthcare than what they do. That's true by far. We spend about two and a half times the OECD [Organisation for Economic Co-operation and Development] average per capita on healthcare. We literally don't need to spend another dime on healthcare in this country, regardless of what anyone will tell you, because we're already outspending everyone else and getting terrible results.

But when you actually look at what they're spending holistically on people, on family and social support services, on green spaces, on making sure people have access to food and good mental health services, they actually do spend about as much money as we do on health. We just spend a disproportionate amount of our money on downstream healthcare.

Until we solve that problem, we're never, never going to get out of this hole.

A super quick story, but I love this story because it's true and it drives home the point. I came home one day from work and we've got two boys, and there was water coming out of my chandelier in my dining room. I run upstairs and I'm like, what the heck is going on? My two boys had flooded the bathroom. They were playing with their toys and flooded the bathroom.

My first instinct was to run to the towel closet and start grabbing towels and throw them on the floor to sop up the water. And I quickly realized that I didn't have enough towels to sop up all the water, and I had to actually go to the root issue and turn off the spigot and prevent the water from flowing out of the tub.

Our healthcare-only approach is throwing towels at the water without turning off the spigot. Until we get upstream and turn off the spigot, we're going to continue having this argument over and over again.

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