Health care is consistently listed by voters nationwide as the No. 1 issue in the 2020 presidential campaign.
So it is no surprise that candidates seeking the Democratic nomination for president as well as President Trump have much to say about a system that accounts for nearly 20 percent of the country’s spending and affects the life of every citizen.
What may be a surprise is that the person who may be offering some of the most sensible answers to our health care system’s problems is not the president or a candidate for the Democratic presidential nomination.
He is instead the president and CEO of New Hyde Park-based Northwell Health, New York’s largest health-care provider and private employer.
As president and CEO of Northwell, Michael Dowling oversees 23 hospitals, more than 700 outpatient locations, $11 billion in annual revenue and more than 66,000 employees. He also served for 12 years as deputy secretary for Gov. Mario Cuomo and as director of health and human services before joining Northwell in 1995.
This has given Dowling a unique understanding of the country’s health-care system, something that he shared last week at a community forum hosted by Blank Slate Media and the Unitarian Universalist Congregation.
Candidates on both sides of the aisle would do well to listen to what he said.
Unlike just about everyone who is running, Dowling said he is optimistic about the future of health care in the United States based on the advances in medicine in areas such as treatment of three of the most deadly diseases – cancer, heart disease and stroke – over the past 30 years.
These advances, he said at the forum and in a book he recently published, have helped bring down the death rate for stroke and heart disease by 30 percent and cancer by 16 percent in recent years.
This, of course, raises the question of why despite these improvements life expectancy has decreased in this country in the past several years.
Dowling has an unexpected answer to that question with implications that go well beyond medicine.
Which is that life expectancy is a result of many factors – with the quality of medical care being among the least important.
More important than medical care in determining life expectancy, he said, are what we eat and how much we eat, how much we exercise, the consumption of things like opioids, firearm ownership as well as weaker social-welfare supports and a lack of universal health insurance.
Dowling pointed out that European countries often have better health outcomes than the United States while spending much less per person. But, he said, they spend much more on the social safety net including prevention and treatment of mental health and addiction.
Studies on mortality, he noted, include both car accidents and gun violence, and Americans are much more likely to die of both causes than people in other countries.
Dowling took a practical view on health insurance.
He called the efforts of Trump and Republicans to eliminate the Affordable Care Act with nothing to replace it sheer craziness that would put 20 million people at risk.
But he strongly dismissed the Medicare for all proposal promoted most prominently by U.S. Sen. Bernie Sanders and single-payer systems offered by European countries.
The single-payer systems of Europe, he said, cover all costs but do not provide the type of access to health care demanded by Americans. Europeans often must wait for long periods to get treatment – a problem that he said European systems have asked for his help in correcting.
And Medicare for all, he said, would be a disaster.
Dowling said Northwell employs at great cost 4,000 employees who work full time to get reimbursed by private insurance companies that reject up to 40 percent of the hospital’s claims.
But Medicare, he said, would be worse.
The payments that hospitals receive under Medicare do not cover a hospital’s costs and no matter how difficult it is getting reimbursed from private insurers, at least you can argue with private insurers, something you can’t do with the government, he said.
And citing V.A. hospitals, he noted that the track record of single-payer healthcare has not been good.
The best way to improve health care, he said, would be to fix the parts of the Affordable Care Act that do not work but to keep the rest intact. This, he said, should include a fix to make health care universal, starting with coverage for every child in America.
He also said the Affordable Care Act needs to be adjusted to allow others to offer health insurance while referring to CareConnect, Northwell’s failed effort at operating an insurance company.
Northwell pulled the plug on CareConnect in 2017, citing high payments required by the ACA’s risk-adjustment pool and a lack of federal assistance – namely that the federal government never reimbursed them the $150 million they were promised.
Dowling said if the payment requirement was fixed, Northwell would rejoin the insurance market.
Dowling also defended the cost of health-care spending in this country, which now stands at more than 18 percent of the economy and is expected to grow to 19.7 percent by 2026.
He acknowledged that money could be saved by eliminating waste, unnecessary procedures, improving insurance reimbursements and reforming medical malpractice.
But the amount spent overall will never go down, he said, because Americans enjoy all the benefits of modern medicine and the number of Americans living longer keeps growing.
There was a time, he said, when people lived with deteriorated hips. Now, he said, they get an operation that lasts 37 minutes and after some rehabilitation, they are better.
Not surprisingly, Dowling also made the case for a network growing to the size of Northwell. He said large health networks provided them with the scale needed to deal with insurance companies, whose delays and denials can put smaller hospitals out of business.
He also said Northwell’s size has allowed it to absorb losses at several hospitals to keep them open. This, he said, provides people with access to hospitals close to where they live.
Unsurprisingly Dowling also offered high praise to a workforce that at least one candidate for president would be unlikely to support – immigrants.
A native of Ireland who grew up poor, Dowling said immigrants bring a work ethic, drive and willingness to accept obstacles often missing from native-born Americans.
For that reason, he said, they are essential to a health care network based in New York. And the health of this country.