Dr Phil Smith of Miami University: “Make preventive care affordable, for everyone”

Make healthcare affordable, for everyone, including preventive care. Healthcare is the leading cause of bankruptcy in the U.S. People choose to forego cost-saving preventive care because they can’t afford it, and access healthcare only when it is an absolute necessity, which usually means very expensive. This is bad for our healthcare system, it is bad […]

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Make healthcare affordable, for everyone, including preventive care. Healthcare is the leading cause of bankruptcy in the U.S. People choose to forego cost-saving preventive care because they can’t afford it, and access healthcare only when it is an absolute necessity, which usually means very expensive. This is bad for our healthcare system, it is bad for people, and it often means a financial loss for healthcare providers who may never fully collect on their services. Making sure everyone has health insurance, through policy, is the way to make this happen. People have tried to lower costs on the supply-side, and it just doesn’t work. For example, some believe that if we stopped using HMOs so much, and returned to fee-for-service insurance, this would help. I think this is short-term memory, because rising healthcare costs was a main factor driving a switch from fee-for-service to a HMO-based systems in the first place.

The COVID-19 Pandemic taught all of us many things. One of the sectors that the pandemic put a spotlight on was the healthcare industry. The pandemic showed the resilience of the US healthcare system, but it also pointed out some important areas in need of improvement.

In our interview series called “In Light Of The Pandemic, Here Are The 5 Things We Need To Do To Improve The US Healthcare System”, we are interviewing doctors, hospital administrators, nursing home administrators, and healthcare leaders who can share lessons they learned from the pandemic about how we need to improve the US Healthcare System.

As a part of this series, I had the pleasure to interview Dr. Philip Smith.

Dr. Smith has been working in public health education, research, and practice for over 10 years. He is currently an Assistant Professor in the Public Health Program at Miami University (Oxford, Ohio), and his work focuses on health equity, women’s health, and public health policy. During the pandemic, Dr. Smith has conducted research on COVID-19 prevention behaviors, and has helped Miami University by researching and developing innovative strategies to help control the spread of COVID-19 on campus.

Thank you so much for joining us in this interview series! Before we dive into our interview, our readers would like to get to know you a bit. Can you tell us a bit about your backstory and a bit about what brought you to this specific career path?

At the end of my college undergraduate years, I was trying to decide between a career as a healthcare provider and a career in public health. Ultimately I decided on public health because I was passionate about the idea of making change in communities and societies. As both a parent of two and as a public health worker, I love the idea of setting people up for success by creating environments where everyone can thrive. My training includes epidemiology, statistics, health policy, and health promotion in communities. I have worked in academic settings and medical schools, and have partnered with governmental and non-governmental organizations to improve public health. I love that my career allows me to constantly learn new things, see things in new ways, meet new people, and work towards positive change.

Can you share the most interesting story that happened to you since you began your career?

A few years after I received my PhD, I made a shift from doing research where I was mostly sitting at a computer analyzing data, to doing research and public health practice in partnership with communities and governmental organizations. One of my first projects, in New York City, was to work with the Department of Health and Mental Hygiene to support public housing communities implement smoking bans on their premises. I had a small role in the work, but working in partnership with community health workers, and hearing directly from community members about the support that they needed, opened my eyes to how little I knew about real-world public health. I considered myself somewhat of a public health expert at that point in time, but when it came to addressing genuine community needs I was pretty clueless. Sometimes we academics take ourselves a little bit too seriously, I think, and sometimes maybe overestimate our expertise and impact. There isn’t nearly enough effort to better understand how community members’ knowledge and lived experiences can drive our research questions and public health work. This is probably the most valuable lesson I have learned since my career started in public health.

Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?

I wish I had a good story like this but nothing is coming to mind! I have made many mistakes I just can’t think of any that are humorous.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

Albert Einstein is quoted as saying, “A hundred times every day I remind myself that my inner and outer life are based on the labors of other men, living and dead, and that I must exert myself in order to give in the same measure as I have received and am still receiving.”

Einstein is as enigmatic as a human being as he was a genius. He used his public spotlight to advocate for civil rights in the U.S. and beyond, particularly for Black/African Americans and Jewish people. I don’t want to only revere Einstein, because he also privately wrote racist comments, particularly about Chinese people. He could be aloof, isolated and arrogant but then profoundly humble. Being honest about ourselves, our heroes, and our history is important. This particular quote captures Einstein’s more humble side. I appreciate the reminder to take a step back and consider how my own career and successes are part of something much bigger that transcends space and time. This sense of connection to something larger than myself, and this appreciation for my teachers, adds a spiritual component to my work. Humility is an essential quality of any good researcher, educator, and advocate for change. Beyond this, humility is central to human beings’ abilities to empathize, love, and connect with each other. The quote also captures a valuing of reciprocity — a sense of giving and receiving; a type of communal living, but with people past, present and future. It’s a really awesome quote.

Are you working on any exciting new projects now? How do you think that will help people?

I am part of a research collaboration that focuses on how tobacco use and addiction influence maternal, fetal, and infant health. We are working on a number of projects. Some of our work focuses on risks of tobacco use, including vaping, during pregnancy. We are also working to conduct and advocate for research that is most supportive for women working through tobacco use and other addictions during and after pregnancy. Research holds a lot of power over shaping the dominant narratives in healthcare and public health. When research focuses solely on harms associated with pregnant mothers’ behaviors, this contributes to a narrative that is stigmatizing, ostracizing, and dehumanizing for moms. This narrative in turn supports punishment of women, both interpersonally and in some cases legally, which is harmful to women’s and their children’s lives. These impacts are worse for women who also identify with oppressed groups racially and otherwise, contributing to staggering disparities in infant mortality in the U.S. Research that authentically captures women’s stories, and looks to authentically support women in the ways that they need, counteracts this predominant narrative of health risk, shame, and punishment around addiction and pregnancy.

Ok, thank you for that. Let’s now jump to the main focus of our interview. The COVID-19 pandemic has put intense pressure on the American healthcare system. Some healthcare systems were at a complete loss as to how to handle this crisis. Can you share with our readers a few examples of where we’ve seen the U.S. healthcare system struggle? How do you think we can correct these specific issues moving forward?

It is extremely important to have realistic expectations for any healthcare system during a global pandemic like we are currently facing. There is just only so much a healthcare system can do to expand in critical ways during a crisis. Much of the challenges of any healthcare system have nothing to do with the healthcare system itself, but rather with the social-political context in which the healthcare system exists. Put bluntly, if everyone had just worn masks and kept their distance, or if everyone who can would get vaccinated, our healthcare system would be in much better shape.

With this said, there were two main ways that the U.S. healthcare system struggled with the pandemic: 1) inefficient production and distribution of resources like tests, and 2) inequitable distribution of resources resulting in disparities across social groups like race and class. Neither of these are new problems by any stretch of the imagination, and the solutions are not new either. When you look at healthcare systems across the globe, there is always a trade-off in priorities: efficiency, equity, and profit. We have one of the least equitable and efficient healthcare systems in the economically wealthy world, but the most profitable by far. When it comes to supply chain — production and distribution of resources — our system is largely driven by profit motives and free market principles at the sacrifice of efficiency and equity. Our attempts to have greater efficiency and cut costs within our commodity-based healthcare system, like our reliance on private HMOs, have not worked very well to drive down costs, improve efficiency, or improve equity. So when a pandemic came along and dramatically stressed particular parts of our healthcare system, the inefficiencies and inequities that were always there just got worse. We have never stacked up all that well compared to other nations in our health outcomes, like infant mortality or life expectancy, and we have similarly struggled with our health outcomes during the pandemic. If we want to change our priorities to efficiency and equity, improving our health outcomes, then we have to get on board with every other economically comparable country in the world and centralize our healthcare system. Otherwise, we make the bed that we lie in, so to speak.

Of course the story was not entirely negative. Healthcare professionals were true heroes on the front lines of the crisis. The COVID vaccines are saving countless lives. Can you share a few ways that our healthcare system really did well? If you can, please share a story or example.

Our healthcare workers are true heroes in every sense of the word. Their sacrifices and ingenuity prevented our 600,000 deaths and counting from being a much worse number. Still, if we want to truly honor our healthcare workers we need to have honest conversations about the socio-cultural and economic forces that required our healthcare workers to make such selfless and heroic sacrifices in the first place. Otherwise I think our celebrations are empty. Similarly with our vaccines — the brilliance and round-the-clock efforts of incredible human beings has made some of us safer, and has brought some semblance of normalcy to some of our lives, at least for the time being. Yet, we also have to be honest about how the inefficient distribution of vaccines globally, driven by nationalism and profit motives, continues to put lives at risk both abroad and at home. We can, and should, celebrate incredible acts of love, while also recognizing that there are powerful forces exploiting those acts of love in the name of power and financial profit.

Here is the primary question of our discussion. As a healthcare leader can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.

This is a really interesting question, because I think that first we need to get on the same page about our goal. What does “improving” healthcare mean? Does it mean improving healthcare for people who can afford it? Does it mean making it more profitable for various industries? Does it mean working towards everyone having access to quality healthcare? People in the U.S. are not even close to being on the same page when it comes to what we want from our healthcare system. For example, look at health disparities. In all countries, including the U.S., income is a determinant of health. However, we are the only country where a sizable portion of our people believe that more wealthy people DESERVE better health. Another example is the increasing number of state policies that require individuals to work to be eligible for Medicaid. If you believe peoples’ worth to society depends on whether they are working, you might support this policy. If you believe human beings fundamentally have value and deserve a basic quality of life, you likely see this policy as a violation of human rights. We are deeply, deeply philosophically divided in this regard. So when it comes to talking about improving our healthcare system, we need to be upfront about not only our goals but our underlying philosophical beliefs and values. I answer this question from a deep conviction that improving healthcare starts with treating healthcare as a human right.

1) Treat healthcare as a human right. The majority of people in nearly every country in the world, including the U.S., believe this to be true. Yet the U.S. is the only country that does not treat healthcare as a human right in practice. Universal healthcare can take many forms, and there are many excellent examples we could use as a model from other countries. Proposals are routinely introduced in congress. These proposals meet resistance for a number of reasons, first among them is the fact that our current healthcare system is incredibly profitable for our pharmaceutical and healthcare industries, and these industries hold great political persuasion. Another reason is that many people in the U.S. hold beliefs about universal healthcare that aren’t true. For example, there is widespread belief that universal healthcare means long waits for necessary care. In fact, the U.S. is only average when it comes to wait times for necessary care. Some countries with universal healthcare do better than the U.S., some do worse. Don’t get me wrong — there are challenges that come along with treating healthcare as a human right. Every healthcare system in the world has challenges. I would just rather deal with the challenges that come with treating healthcare as a right than the challenges and injustices that come along with treating healthcare as a commodity.

2) Make healthcare affordable, for everyone, including preventive care. Healthcare is the leading cause of bankruptcy in the U.S. People choose to forego cost-saving preventive care because they can’t afford it, and access healthcare only when it is an absolute necessity, which usually means very expensive. This is bad for our healthcare system, it is bad for people, and it often means a financial loss for healthcare providers who may never fully collect on their services. Making sure everyone has health insurance, through policy, is the way to make this happen. People have tried to lower costs on the supply-side, and it just doesn’t work. For example, some believe that if we stopped using HMOs so much, and returned to fee-for-service insurance, this would help. I think this is short-term memory, because rising healthcare costs was a main factor driving a switch from fee-for-service to a HMO-based systems in the first place.

3) Address social determinants of health through our healthcare system. Much of our approach to healthcare is still based on what works for wealthy, white, male individuals. There is a wealth excellent research documenting this injustice. This injustice is rooted in history and stems directly from the fact that wealthy white men make the majority of decisions about and within our healthcare system. What would our system look like if we envisioned a system meant to work for everyone? There are courageous people who have been asking this question and trying to change healthcare accordingly. Jack Geiger is a name that often comes up as an early innovator, but many, many others. If we wanted healthcare to be for everyone, we would consider social determinants of health such as access to nutrition, work conditions, immigration status, neighborhood conditions, education, housing, transportation, and exposure to racism as critical to health and healthcare.

4) Prioritize preventive care. This is incredibly difficult to do when our healthcare system is organized around profit motives. Vaccines are an excellent example. Vaccines are one of the most cost-effective healthcare strategies in existence. Yet, generally, vaccines are not the most profitable market for pharmaceutical companies. A lot of logistical challenges go into making vaccines, and people do not need vaccines as regularly as many medications. There is also a lot of financial risk involved when people sue pharmaceutical companies because of adverse reactions to vaccines. There was a period not that long ago when only a few pharmaceutical companies were really interested in the market, and the U.S. government had to step in and create a program to make vaccines more lucrative and less risky for pharmaceutical companies. This has changed as global demand for vaccines has increased, and of course there is great demand and need for the COVID-19 vaccines. Still, in all aspects of healthcare, it’s the tertiary care that is most profitable, not the preventive care. So it is a constant battle to prioritize the preventive care that would save Americans money in a number of ways. Preventive care means less expensive tertiary care, but it also means a healthier insurance pool, driving down insurance premiums. More emphasis on preventive care would create a more cost-effective healthcare system, which could save tax-payers money, or at least would mean more taxpayer dollars spent on other important priorities.

5) Greater emphasis on comparative effectiveness and cost-effectiveness. This point is related to all of the other points above. When a healthcare system shifts from profit motives to quality and affordable care for all motives, there comes a necessary shift in priorities. No longer are we searching for extremely expensive treatments that primarily benefit the wealthy despite marginal gains in effectiveness; we are searching for the greatest good at the cheapest dollar. For example, say we have treatment A and B. They both work similarly. Treatment A results in greater profits and is more expensive. In a profit-driven system, there will always be a motive to pursue treatment A. Our HMOs and insurance companies somewhat balance out this motive, because more expensive care means more expensive payouts to providers, but the profit motive on the healthcare supply side is always there. In a system driven by quality and affordable care for all, treatment B is the real winner. Maximizing effectiveness at a minimum cost becomes a necessary priority. In the U.S., we have efforts to conduct this kind of comparative effectiveness and cost-effectiveness research, but we there are very powerful forces pushing in the opposite direction, and we are nowhere near the level of prioritization as countries like the U.K., for example.

Let’s zoom in on this a bit deeper. How do you think we can address the problem of physician shortages?

You may have heard our healthcare system described as a tale of two cities. Physician shortages are an excellent example. If all that I had to go off of was my own experience, I would say, “what physician shortages?” I have health insurance, and have never had any major issues with seeking healthcare for myself or for my family, from providers that look like me, talk like me, and understand me culturally. When we look at the country as a whole, and particularly for those who are systemically disadvantaged, the data show a very different story. With this said, physician shortages are not unique to the U.S., and there are complex and highly debated causes. Any solution is equally complex. One solution is to increase funding for and emphasis on preventive care. Another is addressing social determinants of health. The more we shift our emphasis to prevention and early intervention, and the more we address the “causes of the causes” of inadequate health, the less specialization is needed. An example is COVID-19. It takes a single nurse to give a vaccine dose; but treating advanced COVID-19 in an intensive care unit requires a team of people that includes highly trained physicians. So we address the supply problem with demand solutions. These solutions are mostly political, because these kinds of decisions are made by politicians and industry barons who make the decisions about budgeting and emphasis of care. These solutions are also cultural — we tend to react rather than prevent. The issue will probably get more traction in the U.S. as provider shortages grow and start to affect a greater number of white, wealthy Americans who hold the greatest political power.

How do you think we can address the issue of physician diversity?

Physician diversity includes all aspects of diversity — race, socioeconomic background, (dis-)ability, gender, nationality, and the intersection of the above. If we are going to authentically address our lack of physician diversity, we need to look our past and present squarely in the face, particularly around issues of racism, sexism, ableism, etc. Unfortunately people who are attempting to confront these challenges face both old and new social and structural barriers, for example in the form of policies banning discussions of critical race theory, policies limiting diversity training, and the like. Medical schools and their recruitment and retention strategies, which need work, are just the tip of the iceberg of the problem. Everything is connected. Addressing inequities in education will help address physician diversity. Addressing inequities in housing, addressing inequities in the criminal justice system, addressing inequities in access to safe and reliable transportation, all of these “causes of causes” will help address physician diversity. I can tell you what does not work — when medical schools and their affiliated hospitals and clinics recruit diverse student bodies and trainees but then do not authentically confront issues of racism, ableism, nationalism, and the like in our medical education and more broadly. Unfortunately, I think this practice is common.

What concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?

These changes are top-down. They are necessarily rooted in policy, and therefore are necessarily political. Otherwise, the titans that devote millions of dollars to maintaining the status quo win. So the best steps towards manifesting these changes are for individuals, leaders, and communities to advocate for and to vote for politicians that support a more humane healthcare system, and a more humane society in general. Corporations can use their immense wealth and power to advocate for change, but changes that benefit society are not necessarily going to benefit corporations’ profit margins. Without policies requiring corporations to change, there may be little motivation to do so.

You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂

I wish my idea was new and brilliant, but it’s an idea that basically everyone else in the world has adopted, and that is that healthcare is a human right. When you make this shift in policy, there is a ripple effect that changes healthcare to maximally benefit as many people as possible at as little cost as possible. As I mentioned earlier, this shift does not come without its own set of challenges, but the whole reason we are having this conversation is because our current system isn’t working all that well. So challenges aren’t anything new. Let’s start from a place of treating everyone like a human being, then work on that set of challenges.

How can our readers further follow your work online?

I wish I was better with Twitter and social media! I am on LinkedIn, ResearchGate, Google Scholar, and I have my faculty webpage at Miami University.

Thank you so much for these insights! This was very inspirational and we wish you continued success in your great work.

Thank you!

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