People often brag that they have “great healthcare insurance.” It is often the most important benefit employers can use to attract new employees. This can be very comforting to people who are concerned about their health and their future. But good healthcare insurance is not an end in itself; it is a means to an end. If the end never comes, what good is it?

There is reason to be skeptical of focusing too much on healthcare insurance instead of the quality of the health care delivered. John C. Goodman, writing for The Independent Institute at independent.org, says, “One reason the United States spends more on health care than other countries is that we are obsessive about health insurance instead of health care. When the British National Health Service or the Canadian Medicare system spends additional money, they spend it employing doctors, building hospitals or buying medical equipment. When the U.S. government spends more money, we give it to insurance companies.”

He cites ObamaCare as an example. According to Goodman, we are currently spending $214 billion a year insuring people through Medicaid (which is mostly contracted out to private insurers) and the Obamacare exchanges. At $1,731 for every household in America, that’s a great deal of money being transferred from taxpayers to insurance companies every year.

It is clear that insurance companies, and hospitals, are benefitting most from ObamaCare. You need only notice the size of their buildings in any downtown metropolitan community. But what about the American people? Are they getting the access to healthcare and the measurable improvements in their health that ObamaCare was supposed to deliver?

Nonetheless, one scholarly study finds there has been no overall increase in health care in the US since the enactment of Obamacare. The number of doctor visits per capita actually fell over the last decade. That’s surprising, because our population has been aging and older people require more health care.

Unfortunately, there is nothing particularly new here. When Obamacare was enacted, it was expected to cost close to $1 trillion over the next ten years. But there was no serious discussion of what we were going to buy with all that spending—not in Congress, not in the mainstream media, or even in the health policy community.

Goodman explains that Economics 101 teaches that all societies face a production possibility frontier. The typical textbook example is the choice between guns (military goods) and butter (consumer goods). In our case, it is health care versus other goods and services. To have more of one, you have to have less of the other. To have more health care, we have to have more doctors, more nurses, more hospital beds, etc. Without any increase in supply, for one group of people to get more care, some other group has to get less.

We saw a vivid illustration of that during the Covid pandemic. In order to tend to the needs of a sudden surge in Covid patients, health care providers had to delay care for the non-Covid patients. That has led to many more undiagnosed cases of cancer, heart disease, diabetes, and other chronic, life-threatening illnesses. The quality of their healthcare insurance didn’t change – but the quality of their health care deteriorated.

History tells us what happens when the healthcare delivery system doesn’t adapt to increased demand. Medicare for the elderly and Medicaid for the poor were huge programs, even when they were started in 1965. In a short period of time the number of people who lacked health insurance dropped from nearly 25 percent to under 15 percent of the population.

As a result, physician visits by low-income people increased 6.2% and surgical procedures among the elderly increased 14.7%. But since there was no increase in the ability of the system to supply medical services, these increases were offset by a decrease in care delivered to the non-poor and the non-elderly.

A study in the American Journal of Public Health found that “society-wide utilization of medical care remained unchanged.” Even though there was an increase in health care services for seniors, MIT professor Amy Finkelstein discovered that the passage of Medicare had no effect on the health of the elderly—at least as measured by mortality. The additional spending set off a bout of health care inflation for all patients, however.

You would hope that Washington politicians would have learned something from this experience. Sadly, there is little evidence of that. During the first term of the Clinton Administration, Hillary Clinton proposed a plan to reform the private health care system and insure the remaining uninsured. But although that proposal consumed thousands of pages of analysis and discussion, almost no one asked what the nation would have less of in order to have more health care. And nothing was done to increase the supply of doctors and nurses!

Has ObamaCare increased the delivery of health care?

Under Obamacare, the number of people without health insurance fell from 15.5 percent of the population in 2010 to 7.9 percent by 2022. Sounds good, huh? Yet the study cited above found that health care utilization across all of society did not increase at all! There was some shifting, as low-income patients got more care, but that care was offset by reductions elsewhere in the system. In particular, “a 3.5-percentage-point increase in the proportion of persons earning less than or equal to 138% of the federal poverty level with at least 1 office visit was offset by small, nonsignificant reductions among the rest of the population.”

It is clear we must focus more on the delivery of healthcare, rather than the insurance of healthcare, if we want to improve the health of all Americans. That is the goal, isn’t it?

It took a viral pandemic to break down the barriers to effective telemedicine, especially across state lines. Now, it seems those barriers are being rebuilt.

Telemedicine, the practice of physicians consulting with patients on the telephone, or more often online with video, became commonplace during the Covid pandemic. Patients, as well as physicians, were reluctant to see people who might be infected with the virus. Therefore, it made perfect sense for patients to stay connected with their doctors through telemedicine since in-office visits were inadvisable. To facilitate these telemedicine evaluations, interstate restrictions were also removed. This enabled physicians to help more and more people during the pandemic, even across state lines.

But now that the pandemic crisis is over, though Covid is still around, some states are reimplementing restrictions on interstate telemedicine. This not only seems petty and unnecessary, but is interfering with access to medicine for some patients, especially those who established interstate doctor-patient relationships during the pandemic.

Shannon MacDonald, a radiation oncologist at Mass General Brigham Hospital in Boston and an associate professor at Harvard Medical School, writes about the impact of these restrictions in an article published in The Wall Street Journal. Dr. MacDonald tells us of a nine-year-old boy from New Jersey she began treating in 2009 with a brain tumor, medulloblastoma. Though the boy and his family traveled between states for appointments, he remained her patient at all times. Telemedicine made it possible for her to answer his parents’ questions, discuss his imaging, and propose new therapies when others failed. He was able to receive state-of-the-art treatment and continuity of care across state lines with the aid of telemedicine.

Though the boy has since died, telemedicine was an integral part of his treatment. You would think that the Covid pandemic would have awakened state governments to the benefits of telemedicine such that the emergency orders permitting interstate treatments would have been permanently waived. But, alas, such is not the case. Some states, like New Jersey (where this boy lived) have rescinded the approval of this practice now that the pandemic crisis is over.

Dr. MacDonald explains: “Instead of enlightening local governments about the benefits of telemedicine, the pandemic highlighted what physicians are forbidden to do. While I never hesitated to pick up the phone to call the boy’s parents and give them advice, I wouldn’t legally be able to do that now because New Jersey has decided that a simple phone call constitutes the practice of medicine. Giving medical advice to an out-of-state patient over the phone can put me at risk of losing my license, and, in states such as California and New Jersey, of criminal charges as well.”

At the outset of the pandemic, some state medical boards feared that telehealth would enable out-of-state doctors to poach patients from local physicians, especially in rural communities. State health authorities also didn’t want the hassle of pursuing malpractice claims across state lines. These concerns were unfounded. Fees and carve-outs—for example, restricting interstate telemedicine to specialty care or requiring referrals—could address these issues without undue limits on access, as could a requirement that physicians adhere to the laws of the state in which the patient is located.

The benefits of telemedicine outweigh any hypothetical concerns. Rural areas lack specialists, but rural residents need specialized healthcare as much as anyone. Distant specialists, accessible to rural residents by phone, shouldn’t be thought of as competitors to rural physicians but as resources capable of extending patients’ lives.

Personally, I have never understood why physicians are not granted the privilege to practice medicine in all 50 states when they pass the National Board of Medical Examiners test, which is required by every state for licensure in the U.S. I’m sure the reason has more to do with collecting state licensure fees than with any concerns about qualifications to practice medicine. I’m sure most doctors would be happy to pay a little more for national licensure, which could be shared with other states. In turn, these states would save money because they wouldn’t have to license these physicians themselves. This is an issue that has more to do with state control and fees than it does with qualifications.

Dr. MacDonald has tried to overcome this hurdle to interstate telemedicine. She explains:

“Without interstate telehealth, I’d have to become licensed in all the states where my patients live if I wanted to continue treating their rare childhood cancers or bone tumors. Because I believe strongly in the benefits of telehealth, I have obtained licenses in six states through the Interstate Medical Licensure Compact. Doing this took months, cost thousands of dollars, and still leaves me unable to care virtually for patients in 43 states. The process is so cumbersome that less than 1% of physicians use it.”

“Military doctors have long been able to practice medicine across state lines. In 2018 it became legal for sports-team doctors to practice medicine during out-of-state away games. If we can make a law that allows treatment across state lines for a National Football League player, can’t we consider it for a child with a brain tumor?”

This is clearly a problem begging for a solution that is in the hands of politicians, not doctors. The time has come for the politicians to make it easier to practice the best possible medicine. Some day those politicians may need access to interstate physicians themselves.

Woke medical education isn’t going away. If you’re a regular reader of this blog, you know I first began writing about woke medical education in 2022, hoping it was a passing trend that would eventually go away. But today there is evidence it is getting worse.

In my last post on this subject, called Woke Medical Education Update, I wrote about Dr. Stanley Goldfarb, former associate dean of curriculum at the University of Pennsylvania’s Perelman School of Medicine. Dr. Perelman was the first to call attention to this situation as early as 2019 in an Op-Ed published in The Wall Street Journal called “Take Two Aspirin and Call Me by My Pronouns.” He wrote, “Concerns about social justice have taken over undergraduate education.” He warned about the “focus on climate change, social inequities, gun violence, bias and other progressive causes only tangentially related to treating illness.”

Grace-Marie Turner, writing for The Galen Institute, says many students say they are admitted to medical schools only if they give the “right” answers to a litany of woke questions. Students are being indoctrinated to see skin color as the most important thing about a patient.

Dr. Marilyn Singleton wrote in a recent Washington Post Op-ed that she “graduated with a medical degree in 1973, a black woman in a class of mostly white men. Since I became a physician, I have seen exactly one instance of racism in health care – and it was from a patient, not a fellow physician. As for my colleagues, I have been consistently impressed with the conscientious, individualized care they have provided to patients of every race and culture. When we all took our oath to ‘first, do no harm,’ we meant it, and we live it.”

The latest evidence of this awful trend is a new editorial from The Wall Street Journal called The New Segregation on Campus. The editors tell us “If you’ve heard that the diversity, equity and inclusion agenda is going away, don’t believe it. An emerging practice at elite medical schools segregates students by race to teach them about alleged structural racism in healthcare.”

They go on to explain: “The University of California Los Angeles School of Medicine requires that first year students take a class called “Structural Racism and Health Equity” as part of the standard curriculum. In one exercise for the course, students divide by racial group and retreat to different areas to discuss antiracist prompts. This is known as racial caucusing, a teaching device that UCLA describes as an “anti-racist pedagogical tool” to “provide a reflective space for us to explore how our positionality—particularly our racial identities as perceived within clinical spaces—influence our interaction with patients, colleagues and other staff.”

Fortunately, there is an organization fighting back. Do No Harm is a group that describes its mission as “eliminating racial discrimination in healthcare.” They say this UCLA practice is illegal – that it violates the 1964 Civil Rights Act. In a letter to the San Francisco Office for Civil Rights, Do No Harm wrote this week that the school’s racial caucusing groups “illegally segregate and separate its first-year medical students based on their race, color and/or national origin” in violation of Title VI.

Medical students in the class are asked to choose which of three racial categories they will identify with. They can select among “white student caucus group,” “Non-Black People of Color (NBPOC) student caucus group” or “Black student caucus group.” In case students think they have a choice of which group to join, a letter from the school makes clear they should sort themselves by how they look to others.” Recognizing the imperfect and problematic nature of our socially constructed racial categories,” the school says, “we ask that you identify the group in which you feel you are most perceived as in clinical spaces.”

The day the civil-rights complaint was filed, UCLA abruptly informed students that the caucusing exercise was cancelled, which suggests that administrators know the practice is legally suspect. In accepting federal funds, schools must agree to abide by Title VI, which prohibits discrimination by race. It contains no exception for discriminating in pursuit of an antiracist agenda. As a public university, UCLA is also governed by the Equal Protection Clause of the 14th Amendment.

When I went to medical school, we had more than enough to learn in the relatively short period of four years to complete our medical degrees. We didn’t have time for learning nonsense like this. Neither do the students in medical school today.