At Tuesday's Democratic presidential debate, talking about health care pretty much meant talking about Medicare for All — again. The controversial idea of abolishing private insurance in favor of a single, government-run program certainly deserves some rigorous back-and-forth. But not at the expense of issues with a much greater impact on our health.
As an emergency physician, I can tell you that the best health insurance in the world means nothing if patients can't reach a hospital in their moment of need. But more than 100 hospitals in rural areas have closed since 2010, and hundreds more are at risk. When hospitals close, ambulance times can increase dramatically, and the additional wait often means the difference between life and death. Candidates, what do you think about that?
Many of the remaining hospitals have cut high-cost services such as obstetrics. Between 2004 and 2014, hospitals serving 179 rural counties stopped being able to care for pregnant women, directly resulting in increases in preterm births and births outside of hospitals. Today, less than half of rural counties have hospitals that provide obstetric care. When laboring women have to drive four hours to get to a hospital, it's not surprising that some deliver on the way and many women have to forgo prenatal care. Debate moderators, a question perhaps?
Health insurance also means nothing if there aren't enough doctors. In Texas, a span of 11,000 square miles is served by just one doctor. More than 60% of all U.S. counties — and 80% of rural counties — lack a single psychiatrist. Some 34 million Americans live in areas short on dental health professionals, and 19 million live in reproductive health care deserts, without access to providers of basic services such as contraception and testing for sexually transmitted infections. Voters, isn't this something you want to know more about?
To be fair, multiple candidates have proposals for stabilizing rural hospitals, funding community health centers, protecting women's health care and incentivizing health professionals to work in underserved areas. But you wouldn't know it from the substance of the campaign so far. The American people need to hear more about these ideas on how — literally — to access care, which is a prerequisite to discussion of how to pay for it.
And beyond that, we need to hear that candidates understand people's everyday health concerns. In the urgent-care clinic where I practice, patients routinely come to me with kidney damage and heart problems because of untreated high blood pressure. Even with insurance, they have to ration prescription medications. Two weeks ago, I treated a patient who cut her blood-pressure pills into halves, then quarters, before she stopped taking them altogether.
I know my patients would be eager to hear how those vying to be the next president would address their struggle to afford prescription drugs. Would they press Congress to allow the federal government to negotiate directly with drug companies? Would they use executive powers to force Big Pharma to cut prices of key life-sustaining medications, such as insulin for diabetes treatment and naloxone, the opioid antidote?
Speaking of the opioid epidemic, candidates must be hearing what I hear: the devastating toll that opioids wreak in rural and urban communities alike, compounded by the tragedy of limited treatment availability. Addiction is a disease for which treatment exists. Yet only 10% of Americans with addictions are getting the care they need. Imagine the outcry if only 10% of Americans who need chemotherapy were getting it.
Marc Lacey, national editor at the New York Times, did ask about the opioid crisis Tuesday. That's good. Many candidates have thoughtful proposals for addressing the crisis. Let's dig into this urgent, on-the-ground health care issue to the same degree we've analyzed the high-altitude pros and cons of Medicare for All. More than a hundred people die every day after overdosing on opioids. How will our next president save lives today?
Finally, we need to hear candidates talk about how to prevent illness in the first place. At the next debate, how refreshing would it be if someone answered a Medicare for All question with a quick pivot: "Let's talk about policies that keep people healthy instead." Prevent our children from getting lead-poisoned. Stop the release of pollutants that worsen asthma. Empower communities to provide healthy food options and walkable spaces. Invest in education, affordable housing and accessible transportation. All these things have as much of an effect on overall health as health care services themselves.
Sound health policy is about so much more than the mechanics of insurance. Let's stop letting Medicare for All dominate the conversation. The United States' patients — the voters — expect much more.
Leana S. Wen is an emergency physician. She was Baltimore health commissioner from 2015 to 2018 and chief executive of Planned Parenthood Federation of America from November 2018 until July. She wrote this article for the Washington Post.
