Americans are frustrated with health care, and rightly so. It’s expensive, confusing and often unfair. I’ve written about its flaws for years. But as calls grow to burn it all down, we risk losing the very parts that are working.
Critics claim the United States hasn’t made progress, that things used to be better, and that our institutions are failing us. In a hearing in Washington on Thursday, Robert F. Kennedy Jr., the health secretary, said, “We are the sickest country in the world.” The Trump administration is using these as excuses to demolish what is best about America’s health and science infrastructure. It’s already eliminated billions of dollars in lifesaving research and proposed a budget that would mean even steeper cuts to public health and medical research. Just last week, Susan Monarez, the director of the Centers for Disease Control and Prevention, was ousted after clashing with Mr. Kennedy over vaccine restrictions, prompting four senior officials to resign in protest. It’s the latest sign of ideology displacing science at the very agency charged with protecting public health.
Such actions imperil the very things we should celebrate.
Take children’s health. Mr. Kennedy often suggests that kids were healthier in the 1950s and ’60s than they are today. But a child with acute lymphoblastic leukemia had almost no chance of survival in 1960; today, the vast majority can expect to be cured. It’s in large part thanks to the C.D.C. that we no longer need to worry about smallpox and polio. Infections caused by Hib (Haemophilus influenzae type b) once hospitalized tens of thousands of children each year, killing or disabling many. I’ve never seen a case as a pediatrician because vaccines have effectively eliminated such infections. Death rates for American children between the ages of 1 and 15 fell more than 75 percent from 1950 to 2018.
Yes, chronic disease is more common in children now, but that reflects both progress and new challenges. The biggest killers used to be infectious diseases; the deadliest of those have largely been eliminated. Obesity is a concern, but it stems more from nutrition and our environment than from failures of the health care system. The rise in neurodevelopmental disorders, like autism, may have more to do with our greater likelihood to diagnose them. No child facing those challenges would genuinely be better off in the 1960s.
The same principle applies to health research. The Department of Health and Human Services spokesman Andrew Nixon said recently that we’ve “thrown billions” at the National Institutes of Health “for decades with little accountability and few measurable outcomes.” This ignores reality. Advances in health care over the last few decades are staggering. People with H.I.V. now live long lives. Many cancers that were death sentences in the 1970s are now curable. Hepatitis C, once incurable, can now be eradicated with a 12-week course of pills.
The N.I.H. is the largest biomedical research funder on the planet. One project aimed at mapping research funding found that it spent 2,500 percent more on grants than the next largest funder that reported data to the initiative. As a result, the United States leads the world in scientific discovery, having produced more Nobel laureates in medicine than the following nine countries combined. Every single drug approved in the United States from 2010 to 2016 was supported at least in part by federally funded research.
The Food and Drug Administration also plays a central role in America’s success. In 2016, more than half of all new medicines released globally originated in the United States. The F.D.A. also approved 94 percent of novel cancer drugs before Europe did, and often in half the time. Other countries routinely wait for F.D.A. approval before greenlighting a new treatment. This is likely one of the reasons you’re less likely to die of cancer in the United States than in Europe.
American institutions continue to train much of the world’s medical work force. Twenty of the top 30 clinical medicine programs are based in the United States. Academic medical centers attract global talent, and about a quarter of U.S. physicians are foreign-trained, many of whom care for patients in rural and underserved communities.
Mr. Kennedy is right about one thing: Americans spend more than their peer nations, but they have worse health outcomes. Life expectancy in the United States has increased since the 1950s, albeit at a slower rate than in other wealthy countries. But this is mainly because America has higher inequality, higher rates of obesity and more homicides, road accidents and drug overdoses. Furthermore, a significant reason we receive so little value from our health care system lies in how we pay for and deliver care.
The Trump administration is looking to cut some of the very institutions that would improve that situation — institutions like the Agency for Healthcare Research and Quality, which studies what works in health care and how we can save money and prevent mistakes. Between 2010 and 2014, an A.H.R.Q initiative to make hospitals safer likely helped avert an estimated 87,000 patient deaths and saved nearly $20 billion in health care costs. Mr. Kennedy is reportedly considering dismissing the entirety of the U.S. Preventive Services Task Force, an independent expert panel housed at A.H.R.Q. that recommends screenings and services and is the reason we can get screening mammograms, colonoscopies and more at no cost. The administration’s push to cut Medicaid and allow Affordable Care Act subsidies to expire will leave millions without access to care.
None of our health institutions are perfect. The N.I.H. could take more risks. The F.D.A. can be slow. The C.D.C. has at times blurred the line between science and public policy. A.H.R.Q. should be better integrated with other agencies. Academic medicine is often too rigid. I share many of these criticisms. But they deserve thoughtful reform, not demolition.
Americans are right to demand more from their health care system. But if we tear down the parts that work — the research, prevention, regulation and education that have driven decades of progress — we won’t be left with something stronger. We don’t need to burn down the house. We need to fix the plumbing.
Aaron E. Carroll is the president and chief executive of AcademyHealth, a nonpartisan group that advances evidence-based health policy.
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