A few months ago, I had to give a patient the worst news.
“It looks like your cancer has returned,” I said.
The man had religiously attended his chemotherapy and radiotherapy sessions in the city’s public health care system up until nine months before. Looking for a little more scheduling flexibility with his appointments, he took a step that seemed logical.
“I got health insurance,” he said, the eyeglasses on his forehead still for a moment. “Everything changed from there.”
Health insurance was supposed to improve his medical experience, but my patient couldn’t find an oncologist or hospital — even in the public system — that accepted his particular type. After months of searching, he grew discouraged; eventually he gave up. “A lot of this is on me,” he told me, ruefully.
This is the level of confusion and complexity we’ve come to accept as normal in our health care system.
I work as an internal medicine doctor at Houston’s Ben Taub Hospital, which is part of a public health system that treats Harris County’s most vulnerable patients, many of whom don’t have insurance. I often see the back end of our insurance fiasco: I’ve cared for dozens of patients who were sent to our E.R. hours after receiving inadequate treatment elsewhere. I’ve felt the injustice of a patient dying after he was dropped by his insurance. I’ve also seen patients hit with unexpected medical bills showing arbitrary prices after visiting the emergency room of a private hospital.
Visiting a hospital or clinic today feels like facing a firing squad, with rounds and rounds of bills coming from every direction. Fewer than half of Americans rate the quality of U.S. health care as excellent or good. We all have our stories. Whether through Twitter rants or opinion pieces or surveys quantifying how many of us grade the system as a failure — 56 percent at last count — we are fed up.
Patients are burned out. Nurses are leaving the profession. Doctors are demoralized. In the meantime, the people not sick or tending to sickness — the corporate middlemen in charge of insurance companies, private hospitals, doctor practices and pharmaceutical companies — are feasting. As Donald Berwick, a former administrator for the Centers for Medicare and Medicaid Services, noted, the “glorification of profit, salve lucrum, is harming both care and health.”
After listening to partisan rants on both sides that aim only to tweak rather than remake our system, I suggest we hold a national referendum on health care. Americans should vote yea or nay on a system that provides basic health care for all.
A federal ballot measure like this has never been held in our country. A referendum would ask Americans to focus on the proposal rather than on a candidate or political party. There’s reason to believe that a direct vote could help us solve our health care quagmire. In a recent survey, about two out of three Americans said it was the government’s responsibility to provide universal health coverage. Another study conducted in my home state showed the same, with seven out of 10 Texans declaring universal health coverage important.
It won’t be easy. Scholars have indicated that it may take multiple election cycles, along with volunteers collecting millions of signatures across the country, to achieve such a monumental feat. Americans are already split about how private insurance would figure into the equation. If history is any indication, those who benefit from our bloated system — the large corporations that keep American consumers in a stranglehold — would brew confusion about the plans in an effort to resist any change.
If the referendum resulted in a majority of “yes” votes, it would send a clear message to Congress and the president: Build us a universal health care system. The hard work of constructing that system and a way of paying for it would start there. Medicare for All, as proposed by Senator Bernie Sanders, would eliminate private insurance that duplicated what was offered in the single-payer system. This standard insurance would eliminate patients’ out-of-pocket expenses and make it harder for hospitals and doctors to cherry-pick those with more lucrative insurance. Multiple iterations of single-payer plans have sprung from Medicare for All, including some that would preserve private insurance. An altogether different plan, a public option, would preserve Americans’ choice to buy private insurance. The drawback would be that without a mandate, health care gaps would most likely still exist.
Controlling health care costs is a problem that has long confounded Americans. For this reason, I favor something different, a public health care system modeled after the one I’ve worked in for the past 12 years. The system provides health care directly — without the middleman of insurance — to nearly half its patients. When it bills a patient’s insurance, the system does so at a reasonable rate, on par with what Medicare pays.
As a resident, I rotated through private hospitals and saw how easy it is to default toward more expensive treatment. In a public system, doctors like me work on salary without financial incentives to overutilize tests or procedures, which further keeps costs in check and patient outcomes top of mind. The lack of a profit motive allows the system I work in to focus on providing quality care while cutting costs. In fact, in 2022, Ben Taub Hospital and the public system saved more than $1.8 billion in health care costs. This amounts to $2.30 in health care cost savings to Harris County taxpayers for every $1 in county taxes collected.
The public health care system in Harris County came into existence thanks to a local referendum in November 1965. The charity hospital that preceded it, Jefferson Davis Hospital, was notoriously underresourced and underfunded. When news spread of its deplorable conditions, citizens decided that the city’s standards had to be addressed. Health care had become a moral issue.
I’m not a specialist; I’m the hospital’s jack-of-all-trades, the doctor tasked with keeping care effective and efficient. As a hospitalist, I don’t have to spend time figuring out if an insurance company will authorize a patient’s treatment. Not worrying about reimbursements means I can focus on medicine. Ours are not easy jobs — our patients often arrive with undiagnosed diseases resulting in one or more organs failing — but at least we can provide good care to everyone. More than 50 years later, it remains as such. I take solace in knowing that I work for a system that tries to help all patients.
After the news sank in of his cancer’s return, my patient asked that I sit down with him. He had things on his mind, questions. He confided to me that his family didn’t know about his illness, and I told him how much I wished he had stayed at Ben Taub and that things had been different. I began to tell him what kind of treatments he might still expect. He stopped me. “I appreciate this hospital so much,” he said. “Y’all are here when no one else is.”
Ricardo Nuila is an internal medicine doctor and hospitalist in his hometown, Houston, and the author of “The People’s Hospital: Hope and Peril in American Medicine.”
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