Having spent two years in Oxford as a Marshall Scholar in the mid-1970s, I came back to medical school believing in a national health service—i.e., Medicare for all. But I learned firsthand that a monopoly can provide access without ensuring quality. When quality isn’t the priority, there’s no hope for lowering costs or alleviating suffering.
Medicare is already the single payer for dialysis and has failed patients miserably. As a result, I don’t support a national health service as other progressive physicians and politicians do.
We already have a large public and an even larger private sector in health care. My suggestion is to make a part of the public sector more accountable. Currently, nobody in health care is focused on preventing disease. Let the Secretary of HHS be responsible for doing so.
My suggestion for an accountable public sector is a reconstituted Public Health Service (PHS), which could care for the 50 million un- and underinsured Americans while keeping private-sector insurance and Medicare intact.
This approach would neatly avoid political opposition. The PHS used to care for thousands of Americans. Its last tuberculosis hospitals closed in the 1950s. But in 1921, it loaned 57 of its hospitals to the VA after World War I to care for veterans lying by the roadside. It’s time to repay that loan with appropriate taxpayer-supplied interest now that the country needs it. The thousands of veterans I spoke to in St. Louis in the 1990s all supported this idea. It would be better to give the VA back to the PHS than to dismantle it piece by piece, as began to happen in the early 1990s.
There is nothing more American than the PHS. It was established by Congress in 1789 and can take care of anybody Congress directs it to, including the 50 million uninsured and underinsured Americans. VA physicians see only a fifth of the patients that private-sector doctors do—200 instead of 1,000 or even 2,000 in the private sector. Having them work a bit harder—five half-day clinics a week instead of just one—would allow them to see everyone at no extra expense.
Besides, the VA/reconstituted PHS has a long-standing tradition of clinical research and teaching. Without it, there would be no academic medicine in the United States.
The Secretary of HHS could order the PHS to improve outcomes and lower costs for common diseases—something nobody in health care currently does. Medicare doesn’t even pretend to. The NIH abandoned clinical research in the 1960s, focusing on “disease mechanisms” ever since. There is no money, for example, to repurpose generic drugs for new disease indications, which is the safest, quickest, and cheapest way to improve patient outcomes.
David W. Moskowitz is a nephrologist and physician executive.
