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Opinion | Michael Apkon

What level of disparity in health care are we willing to tolerate?

Globe Staff; Adobe

The United States leads the world in health care innovation, but we are tragically dead last as compared with other high-income countries when it comes to keeping our citizens healthy. While those in other countries have access to regular physical exams and a wide range of preventive care regardless of their economic status, the only level of care we, the richest nation in the world, guarantee every resident is a trip to the local emergency room. I believe we can — and should — do better.

Most people would probably agree that treating someone after they become sick enough to need emergency care is not the best way to deliver health care, particularly when as many as a quarter of ER visits may be preventable. Emergency care is expensive, and overuse is one reason our per capita health care costs in the United States exceed $10,000, where most other countries spent half that amount for similar or better outcomes.


We know our system is not working and have begun to hear debate from those running for office in 2020 on how to fix it. The problem, however, cannot be solved until we address one fundamental question: What is the basic level of health care services that everyone should be able to access? If we hope to increase the health of the nation and eventually lower our health care costs, we must agree on a minimum defined set of benefits for every member of society. Those benefits must include access to basic primary care and hospital services.

As someone who studies global health care models and who has worked in the United States and Canada, I have experienced — as a physician, hospital administrator, and patient — differential and universal health care systems. In the United States, those with good jobs, premium and supplemental insurance, or ability to pay out-of-pocket, have greater choice in where to receive their care and often can get it sooner. Yet 28 million Americans do not have health insurance at all. In Canada, government-funded universal coverage provides the exact same benefit for every resident. Britain and some other countries offer a hybrid of these approaches. No system is perfect, but I believe a thoughtful government can and should play a role in addressing issues that the market cannot correct on its own.


Affordable access to services makes a difference in the health of a society. Take the lives of people born with cystic fibrosis, an inherited disorder that destroys the lungs and other organs. Those with CF in Canada live on average 10 years longer than those in the United States, where the CF survival rate varies based on the quality of the patient’s insurance coverage.

For some, the idea of government orchestrating even a minute piece of our health care system may be inconceivable and a bridge too far. But terms like “universal coverage,” “single-payer model,” and “health care for all” need not threaten our free-market society. After all, government manages health coverage for those over 65 (Medicare) and for our veterans, but both groups retain some level of consumer choice. Federal and state agencies already strictly regulate hospitals, insurance companies, drug manufacturers and others for safety and compliance.

There are many benefits of government involvement in health care, including ensuring citizens have access to essential medical and preventive services. In the United States, those living in rural areas may travel for hours to see a doctor. The Canadian government drives equity by supporting innovation such as telemedicine and redistributes dollars and medical resources to meet remote needs. Government involvement would also save money. Our current complex system carries a costly administrative burden due to varied fee schedules, payers, networks, and more. This results in surprise hospital bills for out-of-network care and frustrated patients. Administrative costs account for 25 percent of hospital spending in the United States, more than double the proportion seen in Canada. I have come to learn that Tufts Medical Center, a lean and efficient organization, spent over $50 million to process paperwork and chase payments in 2018. As CEO of SickKids in Toronto, a hospital of similar size, I found that the cost was just over $1 million. I believe these dollars would be better used to deliver basic primary care services to those with the greatest need.


Just how much of a role should government play in redefining health care? Should it be part of the planning and delivery of services? Should it fund all or part of them? What options should be available for those who want to pay for more or better services? These are the questions we should be grappling with as we work to find the right formula. While we debate the possibilities, we must stay laser focused on the goal of providing every person with a base level of medical and preventive services. We can no longer tolerate high disparities in health care. As other nations have shown us, we don’t have to.


Dr. Michael Apkon is president and CEO of Tufts Medical Center and Floating Hospital for Children.