By Robert Pearl, MD | | September 15, 2016

With the presidential election now less than two months away–and the first televised debate set to air on September 26–the national argument about healthcare so far has focused mainly on the Affordable Care Act, egregious drug pricing and issues like Zika funding and the epidemic of opioid abuse. Each of these topics is important, and worthy of presidential attention.

But what has gone unaddressed are the broader consequences of how our current healthcare system is organized and functions, and their impact on our nation’s economic and social health if nothing is done to address them. Although the president lacks the authority to legislate or force by executive order a change in healthcare’s underlying structure, method of reimbursement and availability of modern information technology, she or he can—by dint of being our nation’s chief executive—use the presidential bully pulpit to spur debate and propose legislation that will move us in the right direction.

The Current Quagmire

Healthcare now consumes 18% of the country’s gross domestic product, the total “goods and services” used by all Americans. At the rate it is growing, healthcare will approach 30% of the total GDP within the next 20 years. It already accounts for 40% of all federal spending, and with 10,000 new people eligible for Medicare coverage each day, healthcare could, if nothing changes, devour every tax dollar collected at some point in the future.

Despite the three trillion dollars spent on healthcare each year, Americans are becoming less healthy, not more. Our quality of care and the health outcomes we achieve remain in the lower half among the world’s industrialized nations, and the average life expectancy is declining for the first time in half a century. For the past two decades, healthcare inflation has taken up a growing proportion of the dollars available for total compensation, contributing heavily to relative wage stagnation. These are not opinions, but facts. And without question, these trends will have powerful consequences for our children and our nation’s current workforce.

Given the grave dangers our country faces due to the shortcomings of our current healthcare system, you might conclude that no topic would be more important for the next president to address. When the economic viability of the federal government, the incomes of the average American worker and the health of our country’s citizens are at risk, presidential leadership is imperative. And if the next president, be it Mr. Trump or Mrs. Clinton, fails to intervene, these problems will only worsen.

Coverage Is Different From Access

Gaining access to affordable healthcare coverage is a powerful factor. Individuals without insurance, on average, live an estimated seven fewer years than those who have easier access to preventive services and effective treatment for acute and chronic medical problems. The Affordable Care Act has taken important steps toward solving the access problem, but coverage will be impossible to maintain unless the rate of healthcare inflation can be reduced.

Price regulation is not a solution. Already those with coverage through Medicaid, particularly in states with low reimbursement rates, have greater difficulty with access and far fewer choices of providers than those with commercial and Medicare coverage. And because the reimbursement through Medicare has failed to keep up with true healthcare inflation, a growing number of physicians are considering refusing to participate in the program, just as they are now avoiding those with Medicaid coverage.

For this reason, “Medicare for all” is highly unlikely to be a solution. The dollars paid won’t fund the full cost of the care provided. Already Medicare pays doctors and hospitals less to provide care than the actual costs. The result is classic cost-shifting. Increasingly, hospitals and doctors across the country have to charge more for the care they provide to those insured individually and through their jobs to make up the difference.

And as a result, out-of-pocket expenses are rapidly rising each year. In 2010, approximately 25% of people had a high deductible insurance product. Today, it is 40%. When you have to pay $5,000 before your insurance kicks in, you often avoid the doctor and delay treatment. The result, if nothing changes, is that the future will bring this country a two-tier system of healthcare, with the middle class and seniors experiencing the same challenges as those in Medicaid do today.

The next president needs to recognize that should this scenario play out, it will be not only a healthcare failure, but also a political liability. Rather than leaving it to his or her successor to address, I encourage the next president to make finding a sustainable solution a No. 1 priority.

Avoidable Deaths in Untold Numbers

When it comes to talking about the quality shortcomings of our nation’s care delivery system, the silence is deafening. Listen to most politicians, and they will identify problems with health insurance availability, coverage and cost as issues our country needs to improve. But almost to a person—and contrary to stark data from independent third parties—they will persist in describing U.S. medical care as the best in the world.

Powerful forces in this country, from drug companies and large hospital chains to national doctor associations, want Americans to believe our healthcare is the best. And for many of those forces in terms of their bottom lines, it is. But for patients, it is not.

Untold numbers of Americans die every year from a combination of failures in prevention, medical errors and disparities in health outcomes based on race, geography and social determinants of health. The number of people dying unnecessarily may total close to half a million when you combine recent data from Johns Hopkins University on medical error with variations in preventive services and reports by the Centers for Disease Control and Prevention on healthcare disparities. But even if only 100,000 Americans die unnecessarily each year, an extensive discussion about healthcare during this presidential election season is long overdue.

The Solution

In presidential politics, whether foreign policy or social issues, candidates are long on defining the problems and vague in offering specific actions they will take. In medicine it is different. First you establish a diagnosis, and then you commit to a particular action plan. To that end, my next column will offer three specific actions both Clinton and Trump might offer as they debate the challenges of being the chief executive of the United States.


This article originally appeared on Dr. Pearl’s column on