While Thomas Jefferson may have written that “All men are created equal” in our Declaration of Independence, nothing could be further from the truth when it comes to health care in the United States. As a physician, I have pledged to ease suffering and heal those who are sick. However, I find that my job has become increasingly difficult over the last several years. The Affordable Care Act (ACA) has limited access for my patients, increased the administrative burden on health care providers and created a market that favors those who “have” over the “have-nots.” I am also deeply concerned about the impact of the “so-called” replacement passed by the U.S. House of Representatives.

Problems (and questions) remain after the latest repeal efforts: How will we cover those Americans who need health care the most — the chronically ill, the poor, and the marginalized? Why is there still no tort reform? Why did we not address the issue of competition among insurers across state lines? What about limiting drug costs by holding big pharma accountable?

Now, there is more evidence that health care in the U.S. remains broken. A new study published in the Journal of the American Medical Association shows that where you live within the United States may have a significant impact on your longevity. In 2014, there was a spread of nearly 20 years in life expectancy based solely on which county in the United States in which you lived. Counties, where residents are more educated and more affluent, had the longest lifespan and, as you might expect, those counties where residents are poorer and have no post-secondary education have the shortest.

Those that are educated and have more financial options are able to focus on prevention and healthy lifestyle habits. Those that “have not” do not have the access to preventative care and cannot afford quality insurance. While they remain insured “on paper” they are effectively uninsured due to issues with access and cost.

Until we focus on prevention for all, we will continue to see such disparities, and we will continue to have the most expensive health care in the world.

The new Republican plan leaves me with little hope. Those that are already marginalized will remain marginalized. Those who need preventative care will be placed into high-risk pools and could be “priced out.” While the House Bill does say that pre-existing conditions will be covered, I fear that by leaving much of this to the States, we will likely create a system in which many are left out. Alternatively, if we were to create a system where we address chronic disease early in the process and focus on prevention of complications and the proper management of the condition, we are likely to be able to close the ever increasing “lifespan gap” that is demonstrated by this most recent study.

Any real reform must include things that will lower cost, increase access, improve choice and care and expect engagement and individual responsibility from patients.

1. Tort reform. We can no longer allow for frivolous and predatory lawsuits against physicians. Fear of litigation increases costs by forcing doctors to practice “defensive medicine” and results in the ordering of costly and often unnecessary diagnostic tests.

2. Allow insurers to compete across state lines. Many counties across the U.S. have either one or zero choices for ACA exchange insurers. This lack of choice results in a limited network of physicians and may create significant issues with access to care. We must allow patients to choose the doctor that is right for him/her. We must force insurers to compete with one another for our business and allowing them to cross state lines is likely to lower costs, improve care and improve choice. By providing better access in all areas of the country, we may be able to lower the life expectancy gap.

3. Place limits on drug prices. Currently, many patients cannot afford the drugs they need. Lack of compliance with treatments for common diseases may be a major contributor to the life expectancy gap. How can we expect patients to improve their health status if they cannot follow their treatment plan due to a lack of financial resources? We can no longer allow drug makers to charge US consumers far more than is charged elsewhere in the world. We must hold big pharma accountable if they are found to be price gouging.

4. Individual responsibility. I firmly believe that patients can play a role in improving their own life expectancies as well. Patients must engage with their health care providers and must participate in their own treatment plan. The treatment of a disease is a team effort. Doctor and patient must work together, but we must be allowed to collaborate without government interference in the exam room.

Kevin R. Campbell is a cardiac electrophysiologist who blogs at his self-titled site, Dr. Kevin R. Campbell, MD. He is the author of Women and Cardiovascular Disease.

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