On February 7, 2017, CNN hosted an interesting debate between Bernie Sanders, Independent senator of Vermont, and Ted Cruz, Republican senator from Texas, regarding the future of the Affordable Care Act.1
While the two did not break any ground as far as healing the rift over health care, they did address certain arguments that have classically defined the Republican and, to some extent, the Democratic positions.
In doing so, they showed clearly why the two parties are having such a hard time moving toward compromise. Nonetheless, the debate was most notable for several arguments proposed by Senator Cruz which, on the surface, appeared to be legitimate rebuttals to Senator Sanders, but with some minimal inspection turn out to be fallacious.
Senator Cruz drew numerous false conclusions based on misinterpreted facts — a tactic that is rampant in Washington among Republicans and Democrats alike. For example, at one point during the debate, Senator Cruz argued that countries with a national health-care system perform less imaging studies than we do in the US. He went so far as to argue that the reason Americans pay more for their health care is because “the United States, population controlled, delivers 3 times as many mammograms as Europe, 2.5 times as many MRI scans, and 31% more C-sections.” This is in fact a very true statement. However, the context in which he said it is extremely false.
It is true that part of the reason Americans pay more for their health care is because physicians order more “stuff.” However, what Senator Cruz implied is that more tests and more procedures must mean better outcomes, and thus better health care. This is just not the case. Over-utilization is a serious problem in the US, particularly when it does not result in better outcomes. Repeat and inappropriate imaging or procedures raise both health-care costs and risk for false positive results — which lead to further downstream testing or procedures, unnecessary patient anxiety, and increased lifetime risk for other diseases due to the additive effects of radiation exposure. Such practices clearly do not improve health care. In fact, they can lead to unfavorable consequences for patients.
Some might try to argue anecdotally that they caught an early lung cancer or breast cancer with what would today be considered inappropriate screening. But it has yet to be shown that such early detection results in improved morbidity or mortality. What has been shown in many cases is that globally screening a population that has a low incidence of disease with ionizing radiation actually increases the incidence of other diseases — and, in some cases, the very disease the screening was intended to detect.
In the last several years, there have been great efforts made by every specialty and subspecialty governing body to reduce the number of unnecessary tests performed on patients. Take, for example, the numerous documents, including white papers, consensus documents, and appropriate-use criteria, that have been published just in the field of cardiology to guide clinicians toward appropriate use of nuclear SPECT, PET, cardiac CT, echocardiography, nuclear stress testing, cardiac MRI, cardiac catheterization and other imaging modalities. The American College of Radiology and the Radiological Society of North America have formed a joint task force with a campaign, called Image Wisely: Radiation Safety in Adult Medical Imaging, specifically aimed at reducing exposure to ionizing radiation from medical imaging.2
The irony of Senator Cruz’s argument is that it supports the use of a national health-care system. In such a system, utilization can be better monitored, practice patterns can be better discerned, and feedback can more easily be disseminated to physicians — not through restrictions, as usually feared by the right, but by something as simple as offering more accurate feedback about their practice patterns to physicians.
A similar situation exists regarding the prevalence of C-sections in the US. There is a rising concern that we are performing too many C-sections — possibly with convenience to mother and physician more in mind than medical necessity. It is no surprise that the US has one of the worst maternal and infant mortality rates in the developed world.3-4
Hence, Senator Cruz did not offer any objective evidence that the US provides superior health care to its citizens when compared to similarly developed nations that offer universal care.
Rather, when his facts are considered within the appropriate historical and professional context, they suggest that our European colleagues are in fact doing much better than we are, and at a lower cost. In other words, arguing that the US offers superior health care because it allows physicians to perform more unnecessary tests is like arguing that your mechanic is a better mechanic because he changes your oil every 200 feet — a practice that would be expensive and would not improve the functioning of your car. Senator Cruz sees such wastefulness as “people exercising free choice.” Yet in an industry where the consumers must trust the consultants about the products they are buying, this hardly seems like a fair choice.
Predictably, his argument progressed towards the threat that a national health-care system would result in rationing of health care. Senator Sanders made an excellent rebuttal when he commented that the US already rations care based on finances. In those developed countries that offer universal health coverage, they may ration by the acuity of disease. For example, in Europe you might have to wait 95 days, as Senator Cruz quoted, for a knee replacement. But, unlike in the US, you’ll eventually get it. However, if you were in a car accident and injured your knee and needed a knee replacement right away, there is no doubt that you would get care immediately. Urgent care and emergencies are not rationed. Moreover, his anecdotal stories of people waiting for care are not unique to Europe. We have all seen the same and possibly worse here in the US. We just don’t talk about it.
The whole fallacy in Senator Cruz’s argument, and frankly the Republican position, is that our system provides choice and “access” to care. What it truly boils down to is a philosophical question that I have argued previously in prior articles. Is the aim of our health-care system to care for human beings or to generate profits for corporations?
If the goal is profit, then we already have the best health-care system in the world — tailored to maximizing profit for insurance companies, pharmaceutical companies, hospital systems, and medical-device companies.
On the other hand, if the goal of a health-care system is to provide sick individuals with appropriate and timely care in order to maintain a healthy and productive society, then it makes little sense to continue having these moot debates.
Physician fears of losing control of their patients and control over the way they practice medicine are understandable. However, such worries are largely unfounded. Further, for those who view capitalism and free markets as the ultimate American freedom, there is no reason that a for-profit system cannot coexist with a national health-care system, similar to how Medicare currently exists along with private insurers. In fact, I challenge Republicans to offer a public option to whatever alternative they propose for replacing the ACA. If they truly believe in free-market policies, then let a public option be available to compete with private insurers. Then, and only then, would they truly give Americans an opportunity to try both solutions and decide what they really want — actual health care or a theoretical access to health care.
- “Bernie Sanders vs Ted Cruz Obamacare Debate Part 1.” CNN. Updated February 7, 2017. Available: https://www.youtube.com/watch?v=xiymr8RhD_k&feature=youtu.be. Accessed February 21, 2017.
- “Image Wisely. ” American College of Radiology and the Radiological Society of North America. Available: http://www.imagewisely.org/About-Us Accessed February 21, 2017.
- Alkema L, et al. “Global, Regional, and National Levels and Trends in Maternal Mortality Between 1990 and 2015, with Scenario-Based Projections to 2030: A Systematic Analysis by the UN Maternal Mortality Estimation Inter-Agency Group.” The Lancet. 2016;387: 462-474. doi: 10.1016/S0140-6736(15)00838-7
- MacDorman MF, et al. “International Comparisons of Infant Mortality and Related Factors: United States and Europe, 2010.” Natl Vital Stat Rep. 2014;63: 1–6.
This article originally appeared on Medical Bag