Dear Senator Gillibrand:

I am an honors pre-med student at the City College of New York who enjoys keeping up with politics. As you know, ever since Roosevelt’s New Deal, the American government has been heavily involved in ameliorating the lives of its citizens; however, healthcare is one aspect of social welfare that the government has struggled to prosper in, as evidenced by the 30 million uninsured citizens and high premiums. The Affordable Care Act is the most recent attempt to address this problem, and I agree with you that this reform has been effective at increasing coverage for millions of Americans. Moreover, along with 15 of your colleagues, you endorsed Senator Sanders’ Medicare for All bill. No one should struggle to find a way to receive optimal healthcare, however, I believe it would be improbable for us to establish a nationalized health care system in a country like the United States of America. In my humble opinion, one practical way to address our healthcare dilemma would be to first create an incentive for medical students who will work as primary care physicians.

Most people who support the notion of a single-payer system tend to compare us with other industrialized nations such as Canada, Norway, Denmark, etc. It may be true that they are able to incorporate an affordable health care system in their country, but we must not fail to acknowledge that their population and demographics are drastically different from ours. Respectively, they have 36 million, 5.2 million, and 5.7 million people. Most, if not all, Nordic countries are also homogenous in race. On the other hand, The United States is often considered a melting pot and has a population of 325 million people. Based on the data from United Nations Population Division, we are the 3rd largest country in terms of population (12). The two countries that reign ahead of us are China and India, which just shows that we are growing exponentially. Insuring a few million citizens seems more probable than covering a nation that is expected to reach 400 million people in the next 40 years. Therefore, we should not compare ourselves with other nations since their method of healthcare is best suited for their unique situation.

The sheer size of our nation could make it challenging for us to deliver universal healthcare. We must acknowledge that besides our populated country, we have to tackle an essential question: How will M4A get funded? The conservative think tank Mercatus Center proclaims that our government could expect to pay 32 trillion dollars—that’s trillion with a T—over the course of a ten-year period (Blahous 2). Mercatus Center senior research strategist and former public trustee for Social Security and Medicare Dr. Charles Blahous affirmed, “the price tag [is] so steep that even doubling all federal individual and corporate income taxes would be insufficient to fully fund [M4A]” (6). It is often said that we don’t plan to fail, we fail to plan. A precise fiscal plan is very much needed. If not, then it appears as if this bill could struggle to survive in the House Committee, which could impede its progression on the Senate floor. Bipartisan support would be the ideal way to approach this, but due to the present-day polarization it will be difficult to appease both parties.

Regardless of where we stand on the political spectrum, we cannot deny that both state and federal entities work together to make America great by applying the fundamental values of federalism. Many believe that a legislation that works at the state level could also be implemented at the federal level. The health care plan that Governor Romney instituted in his home state of Massachusetts back in 2006 was the precursor to Obamacare. President Obama was able to sign this health care reform, not only because we desperately needed change, but because it was inspired by a health care plan that was somewhat successful at the state level.

One state that dealt with Obamacare was Vermont. On May 26th, 2011, Senator Sanders’ home state passed a plan called Green Mountain Care, in hopes of establishing a government-financed healthcare system. However, when it came time to actually implement the reform, Governor Shumlin had reversed his position, citing that the initiative would have been too costly and the tax increase was higher than expected. My concern is how could we assume Medicare for All would work at the federal level, if a similar reform failed in a state with a population of merely 600,000 people?

There is one possibility that Democrats can push for and still stay true to their progressive agenda: incentivize primary care. Serving and leading the academic medicine community, The Association of American Medical Colleges (AAMC) revealed in a recent report that we will see a shortage of up to 120,000 physicians by 2030, impacting patient care across the nation (Heiser 5). AAMC President and CEO Darrell G. Kirch, MD even commented, “With the additional demand from a population that will not only continue to grow but also age considerably over the next 12 years, we must start training more doctors now to meet the needs of our patients in the future.” In other words, it is imperative we address the shortage of doctors because as Americans grow older, they require more healthcare services. It would be beneficial to adjust our status quo by promoting quality primary care, as it plays a crucial role in everyone’s lives.

I personally believe that quality should be given the utmost importance in any service. In most developed countries healthcare systems emphasize this as well. According to the Journal of American Medicine (JAMA), many nations try to balance all sides of the “health iron triangle”: access, quality, and affordability (Carrol 1). However, there is not a single system that can address all three without disrupting equilibrium. JAMA asserts that there can only be two dominant aspects, implying that one side, unfortunately, has to suffer. It must be acknowledged that quality healthcare is delivered mostly through the expertise of doctors. If we have too few, which seems like what we will be seeing in the near future, then there will be havoc and meager quality in the system. In Senator Sander’s current proposed plan there is no element that addresses this setback. You must recognize that if healthcare becomes universal, more people, basically all 325,000,000 residents of the United States of America, will have access (Hsu et al. 5).

Guaranteeing basic health services such as regular checkups will, no doubt, attract any sane American who was unable to afford it prior to the passing of this legislation. This could potentially lead to longer waiting times. In a recent survey, the healthcare firm Merritt Hawkins revealed that the time to schedule an appointment in 15 major U.S cities skyrocketed by 30% (Rege). On average, the appointment waiting time in metropolitan areas used to be 15 days, but now it is 24 days. The growing physician appointment time is a strong indicator that our country is experiencing a shortage of physicians. This will certainly lead to a system that is just waiting to implode from the immense stress; the likes of which we probably will have never seen before.

Along with the administration hassle and ridiculous appointment waiting times, the healthcare system predisposes general practitioners to several anxieties. We are now seeing that medical students are deferring to specialties other than primary care due to the lack of compensation and tremendous amounts of student loans (Heiser 17). The average medical student comes out of school with about $200,000 in debt. I doubt anyone would be able to go about their day without this immense thought constantly piercing their conscious. Obviously, money shouldn’t be the core reason for graduates to pursue residencies with lucrative pay, but these bright students have to put food on the table. Thus, we must propose an incentive to medical students who agree to work as primary care physicians. These students have already decided to devote themselves to improve the lives of Americans by promoting health, so then why can’t we alleviate them from their half a million-dollar loan? In the end, this will be a smart investment that will benefit not only the under-served urban communities lacking primary care, but the nation as a whole. Moreover, even though we have yet to see a well-thought fiscal plan for Medicare for All, this incentivization may potentially help strengthen the bill, as it will show that we will have enough doctors to meet the demanding implementation of a reform with such magnitude. Most importantly, all current and future medical students are a beacon of hope. We must take advantage of the time and incorporate them into a blueprint that will help engineer our future healthcare system.

In hopes of appealing to intrinsically motivated students and making careers in medicine more attractive some schools have already begun to take meaningful measures. This past August the nationally renowned medical school NYU Langone Health vowed to waive the tuition of all MD students. A medical school in our own state realizes the effect of relieving the burden of student loans, so why can’t we do something similar on the national level? Provided that these students agree to immerse themselves in primary care for a certain time period, the government should waive their tuition. Conversely, if these students fail to uphold their side of the contract, then the government has the right to demand that the students pay back their loan with the most appropriate rate of interest. I believe this type of legislation would garner the support of both the GOP and the Democrats since the overarching goal of the incentivization would be to provide quality medical services to the American people.

Instead of attempting to pass a legislation like M4A, which will greatly exhaust the significantly limited number of primary care physicians and their diligent staff, I strongly urge you to propose a bill that incentivizes producing more general practitioners. I will admit that I still have a lot more to learn about our intricate system. Moreover, I am an avid follower of your Twitter handle and even have notifications on. I am just living up to one of your motivational tweets: “Your voice matters. Every time you call Congress or speak out for change, you’re making a difference.” I applaud you for your ten-plus years in public service, and I hope you continue to represent our interests at Capitol Hill.

Sincerely,

Robby Lyallpuri

                                       Works Cited

Blahous, Charles. The Costs of a National Single-Payer Healthcare System. Arlington: Mercatus Center at George Mason University, 2018. 29 October 2018.

Carroll, Aaron E. “The “Iron Triangle” of Health Care: Access, Cost, and Quality.” The Journal of the American Medical Association (2012).

Heiser, Stuart. The Complexities of Physician Supply and Demand: Projections from 2016 to 2030. Washington D.C.: IHS Markit Ltd, 2018.

Hsu, Justine, David B Evans and Ties Boerma. “Universal health coverage and universal access.” Bulletin of the World Health Organization (2013).

Rege, Alyssa. Becker’s Hospital Review. 9 June 2017. 2 November 2018. <https://www.beckershospitalreview.com/hospital-physician-relationships/patient-wait-times-in-america-9-things-to-know.html>.

United Nations, Department of Economic and Social Affairs, Population Division (2017).

World Population Prospects: The 2017 Revision, Methodology of the United Nations Population Estimates and Projections, Working Paper No. ESA/P/WP.250. New York: United Nations.

 

Robby:

This letter is difficult to find fault with. I might demur about the cost to the government of relieving loan debt for so many med school students (all of them or just certain high-achievers?), otherwise this letter convinces with its fair-mindedness, respectful tone and wealth of research. You write with remarkable poise and eloquence for a college student at any level, much less a freshman. Your rebuttal of the Norwegian model for Medicare for All in America was cogent, and you don’t then torpedo MfA, you just say its realization is far away, while your proposal is practical in the near future. This measured approach helps to avoid alienating Gillibrand. The common ground established at the beginning over ACA’s successes was excellent, and your transitions were much better in this draft. With your research and quoting conducted at such a scholarly level, I think this letter is as convincing as could be hoped. Well done! [A]