Operation waitlist: barriers to life-saving surgeries
Rishabh breaks down the different barriers to care and explains how surrounding resources can influence surgical outcomes.
Even with the dazzling advancements in healthcare in the past 50 years, barriers to care seem to remain an unfortunate motif that stands in the way of improved collective health outcomes. Limited access to healthcare leads to suboptimal care for patients, which can carry serious consequences for some of the most acute cases—particularly those who require emergency surgical intervention. The conversation surrounding available resources and surgical outcomes is not a new one, and many of these disparities have been characterised over the years across various surgical subfields, from surgical oncology to paediatric neurosurgery. To make matters more complicated, the COVID-19 pandemic serves as an additional stressor and has compounded the strain on healthcare systems trying to meet the needs of their patient population.
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First, a number of pre-existing upstream elements can impede a patient’s ability to seek care. The social determinants of health are factors that include characteristics of a patient’s environment that may appear far removed from formal healthcare processes, but still significantly affect the patient’s health outcomes. For example, a patient’s limited access to nutritious food, clean water, education, and a safe living environment may predispose them to more serious conditions and complications in their surgical care than if they enjoyed unrestricted access to such resources. This too has been studied extensively, leading organisations such as the Centres for Disease Control and Prevention in the United States (US) to develop a myriad of programmes targeting the social determinants of health in underserved communities. Similarly, on the healthcare systems end, limitations in resources result in unequal outcomes. Rural and county hospitals experiencing personnel shortages, overwhelming demand for operative treatment, and limited financial assets, tend to fare worse than their counterparts in outcomes such as post-operative mortality. This is deeply concerning, given that rural and county hospitals often care for patients with more comorbidities and limited resources.
In the last year and a half, the COVID-19 pandemic has further strained an already stressed system in the US. As a result of personnel shortages, bed unavailability, and the precautionary delay of non-urgent operations, there is currently a significant backlog of desperately needed surgeries. Taken together, these factors have also led to the loss of revenue for academic and non-academic hospitals, jeopardising their ability to take care of patients in the future. Even so, the COVID-19 pandemic has not affected all hospitals equally. In the US, safety-net hospitals—which care for the uninsured and underserved—saw their profits dwindle, while their private counterparts experienced an increase in revenues. In part, this discrepancy is due to anticipatory financial planning by private hospitals, but it is also a result of the federal government’s pre-pandemic initiative to allocate relief funds to hospitals commensurate with their revenues. Additionally, because the safety-net patient population tends to be sicker, more vulnerable, and require more intensive resources, these patients have suffered disproportionately along with the very hospitals tasked with caring for them.
“Bridging the resource gap and the outcome chasm cannot be achieved in one day. Indeed, social inequities present barriers to patient care in healthcare systems around the world. ”
In response to this exacerbation of existing disparities, hospital systems around the world have taken steps to provide adequate care. After all, the consequences of complacency in the face of limited resources are dire. Backlog in the cancer referral pathway, for example, could cause a significant excess in death rates according to a study designed to measure the effects of delayed referral in the United Kingdom. To optimise resources, various techniques have been implemented to ensure surgical services can operate on as many patients as possible before their disease progresses. One such technique was deployed in a hospital in Hong Kong, which created a tiered system of cancer subtypes and assigned target completion times for the respective operations, leading to some alleviation of their waitlist burden. Furthermore, the National Comprehensive Cancer Network has provided guidelines for resource allocation and triaging systems during the COVID-19 pandemic. These guidelines help hospitals streamline their care so that they may treat as many surgical patients as possible given the realities of resource shortages. While endeavours such as these have eased some of the strain on healthcare institutions, systemic factors continue to unduly affect disadvantaged patients.
Bridging the resource gap and the outcome chasm cannot be achieved in one day. Indeed, social inequities present barriers to patient care in healthcare systems around the world. While steps have been taken to address these disparities, further investigation into potentially implementable solutions is more important now than ever. The goal of this pursuit is to ensure that all patients, regardless of their backgrounds or means, receive the surgical care they need.
The new red scare: how rhetoric shapes the US healthcare system
Page argues that the rhetoric surrounding universal health care often plays into fears and misconceptions about a lingering socialist threat in the US, preventing the implementation of a more equitable and effective healthcare system.
“The current system is both economically inefficient and inequitable, and there is no reason that universal healthcare could not be implemented for a reasonable price tag.”
It is old news at this point that the United States (US) is one of the richest countries on the planet, but consistently ranks low across multiple metrics of healthcare quality in comparison to other countries with a similar gross domestic product (GDP). While there are many factors that contribute to the difficulties of delivering healthcare consistently across the US (not least its sheer size), the fact remains that among its higher performing peer countries, the US is the only country that does not have some system of universal healthcare.
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Support for universal healthcare among the American public has risen in recent years. Despite this, the idea of actually implementing it remains highly controversial, ostensibly due to the concern that it would be exorbitantly expensive. However, in reality, the US spends vastly more on healthcare per person than its peer countries with universal healthcare systems. In 2019, the US spent an eye-watering 17.7% of its GDP on healthcare, with nearly half of that coming from federal, state, and local governments. By contrast, Japan spent 10.9% of its total GDP on healthcare in the same year, and Germany 11.2% in 2017. In 2019, 10.2% of the United Kingdom’s (UK) total GDP went to healthcare, 79% of which was government funding. In other words, the US government is spending nearly the same percentage of its funds on healthcare as the UK government, but US citizens are more than doubling the country’s expenditure through insurance payments and out of pocket costs. The current system is both economically inefficient and inequitable, and there is no reason that universal healthcare could not be implemented for a reasonable price tag.
Here, I am not interested in discussing in detail the breakdown of US healthcare spending. Rather, I ask you to consider why the fallacy that universal healthcare would be unfeasibly expensive has persisted, when universal coverage has been achieved many times in other countries at much lower per capita costs than those in the US currently incur.
Healthcare is a highly political issue in the US, and much of the rhetoric surrounding universal healthcare seems to be left over from the Cold War. During the lead-up to the 2020 presidential election, universal healthcare (under the title “Medicare for All”) was, for the first time, floated as a legitimate policy position by multiple candidates. During this time, Fox News talk show host Tucker Carlson said, “Medicare for All is actual socialism, ‘for real’ socialism … Why do you think we don’t have it already? Because we can’t afford it.” He then proceeded to paint a vivid image for his three million some viewers of then presidential candidate, Senator Elizabeth Warren, having “complete and unquestioned control of America” under Medicare for All. “She is the most powerful person in the world—you can almost hear her repeating the phrase to herself,” he lamented.
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It may be unclear to the viewer what Mr Carlson’s definition of “socialism” is, but whatever it is, it’s bad. One imagines Senator Warren lording over the American populace with an iron fist as they are forced to give up their dental coverage to pad her coffers in the era of “socialised medicine”. This Red Scare-esque use of language is nothing new—The Affordable Care Act (ACA), colloquially known as Obamacare, was subject to similar rhetorical treatment by conservative political commentator Bill O’Reilly in 2014, and by Fox News: “Obamacare is much more than providing medical assets to the poor—it's about capitalism versus socialism.” Further examples abound; the ACA has been variously referred to as “the crown jewel of socialism” and a “centralised health dictatorship”. Former presidential candidate and MD Ben Carson once proclaimed, also on Fox News, that Vladimir Lenin had called socialised medicine “the keystone of the arch of the Socialist State”. This quote has not actually been linked to Lenin, and was likely fabricated during the 1940s when the American Medical Association launched a propaganda campaign against one of the first universal healthcare bills. This rhetoric, especially in spoken language, is successful because it plays off American distrust of big government, values of self-sufficiency, and belief in free-market capitalism; it is designed to induce a response of fear.
But let’s look at the facts—compared to peer countries, the US has low life expectancy; high infant and maternal mortality; high rates of teen pregnancy and sexually transmitted infections; high disability prevalence; and high rates of diabetes, heart disease, chronic lung disease, and obesity. A recent analysis also found that in addition to health outcomes, the US ranked last among 11 other high-income countries in terms of access to care, administrative efficiency, and equity.
“The first step to developing a system that works for everyone is to end fearmongering and combat misinformation.”
The issue, clearly, is multifaceted, and there are no easy answers. Some of the issues with the system overlap with larger inequalities within the country; for instance, the US has much wider disparities in access to care by income than its peer countries, and black mothers have higher rates of maternal mortality regardless of socioeconomic status or education. However, costs are high across the board compared to peer countries. In a recent analysis, 22% of US patients recorded serious problems paying medical bills, over twice as high as the next highest country, France. 34% of US patients reported their insurance denying or underpaying for care, again double the next highest country’s rate. It is worth noting here that increasing insurance coverage only does so much when insurance fails to cover costs. In 2017, over half of those experiencing catastrophic healthcare costs in the US were insured. Even for those who can afford coverage, medical bills can be devastating when a sudden illness or injury occurs.
The misconceptions surrounding universal healthcare in the US must be addressed. Many Americans worry that universal healthcare would increase their wait times or restrict their choice of provider. In reality, other countries with universal coverage have achieved comparable or even lower wait times, and even in the UK’s single payer system you are perfectly at liberty to choose which practice you attend. In fact, in some countries with universal coverage, such as Germany, many citizens opt for private insurance. Others are concerned that adopting a universal system would increase administrative costs; however, the US already devotes a larger proportion of its health spending to admin than its peer countries with universal healthcare.
I am certainly not equipped to offer an easy solution here. The American healthcare system is a vast and complex entity, and what works well in any other given country may not be the best solution in the US. However, I can say that no one should be left with the double burden of a dead loved one and a six figure hospital bill, or die from rationing insulin after aging out of their parents’ insurance plan. The first step to developing a system that works for everyone is to end fearmongering and combat misinformation. No, universal healthcare will not send us hurtling back through time and space to the USSR. But it just might save a few bucks—and a few lives.