By Augie Lindmark, Vanessa Van Doren, Bryant Shuey, and Andy Hyatt in STAT News, October 25, 2017. Photo: Students for a National Health Program.

Underneath a heap of hospital blankets, Stephen seemed small for a 7-year-old. His chest rose and fell rapidly, a frightening rhythm given his history of asthma. His parents stood nearby as veteran witnesses — Stephen had been admitted to a Cleveland safety net hospital for asthma four times already this year — but familiarity offers little comfort when your child struggles to breathe. When asked if their son used his asthma inhalers, they replied, “It depends. When we can afford them, he takes them. But when we can’t, it could be a few weeks.”

Stephen represents one of more than 430,000 hospitalizations each year due to asthma. At a cost of $56 billion annually, complications from asthma can be prevented with regular medications (inhalers), avoidance of triggers like dust and mold, and access to health care, which usually means access to health insurance. Stephen didn’t have the latter.

Of the diseases we are taught in medical school, a sudden worsening of asthma, known as an exacerbation, is a relatively common cause of illness in children and adults. To identify the cause of a disease, doctors are trained in the differential diagnosis. This bedrock of medical education encourages doctors — those in training, like us, as well as those with years of experience — to compile a list of causes that match a patient’s symptoms. In a way, the differential is half medicine, half Sherlock Holmes.

Chest pain, for example, might include differential diagnoses that range from heart attack to having eaten too many buffalo wings. Yet there’s a particular cause of illness — in Stephen’s case, a nonpulmonary culprit — that is unique to American health care: America’s private health insurance system.

Recent months provide ample context. As the latest Obamacare repeal efforts took the form of Graham-Cassidy 1.0 and 2.0, the GOP bill would have kicked 32 million Americans off their health insurance. Patients with preexisting conditions like asthma would have seen sharp increases in their health insurance premiums (in the case of metastatic cancer, to the tune of six digits), and Medicaid reimbursements to Planned Parenthood would have been banned, effectively barring millions of women from reproductive and preventive health care.

Both Republican and Democratic efforts have done little to change the fact that thousands of Americans die from lack of health coverage. America’s fragmented and inequitable health system is a sinking ship and recent fixes — often in the form of private health insurance industry bailouts or shutouts — are like placing tissue paper over the leaks in this doomed vessel.

No bacteria or viruses harm health more than policies that effectively prevent millions of individuals from access to affordable health insurance to pay for life-altering health care, including the recent ill-conceived executive order. As American health care maintains its appalling position as a leading cause of financial burden and bankruptcy, an equitable response is essential. That means creating a system in which access to health care is based on need, not the ability to pay. As future doctors, we are being trained to identify root causes of disease. That’s why we support Medicare for all.

Momentum toward an improved and expanded Medicare for all health system is at historic highs. The majority of American physicians now support single-payer health care, and 60 percent of Americans believe that the federal government has a responsibility to ensure health care for all citizens.

Last month, the Medicare for All Act was rolled out with fanfare as Sen. Bernie Sanders — joined by 16 co-sponsors — offered a blueprint for universal health care in America. Its sister bill in the House of Representatives, the Expanded and Improved Medicare For All Act, has 120 Democratic co-sponsors, making it the first single-payer bill in history to have a majority of Democratic support.

The overwhelmingly popular Medicare and Medicaid programs have saved millions of lives and offer strong, supportive health care to millions of Americans. Why not offer that to allAmericans? As the life expectancy gap between rich and poor increases, the only path forward is to ensure that all Americans have affordable health care, regardless of socioeconomic background.

President Trump recently declared his desire to “stabilize markets” which, historically, has meant diverting funds to private insurers who have done an outstanding job of shrinking coverage and fattening corporate profits. Trump’s latest executive order, which eliminates select private insurance subsidies, will ironically dampen private profits at the expense of escalating premiums for the middle class.

Private insurance subsidies are Band-Aids on an already oozing wound, an inefficient private industry that prioritizes the depth of shareholder pockets over patient health. And while subsidies are short-term fixes inadequate for a long-term solution, removing them altogether, as has been the procedure in the latest GOP bills, would further limit patient access to affordable, comprehensive care. This worse-worst situation could be healed with an improved Medicare-for-all system that eliminates profit motives and preferentially places health above all else.

As medical students, we occupy a unique seat from which to view America’s health system. Our inexperience means we haven’t been indoctrinated into the damaging practices of the private health insurance industry. Our optimism tells us that the system can be changed. We entered medicine out of a desire to help people. But if we participate in a flawed health care system without advocating for structural and equitable change, we trend toward hypocrisy rather than Hippocrates.

Because Stephen’s parents couldn’t afford asthma medications, their son’s breaths were figuratively assigned a price tag. His family, like millions of Americans, is forced to make an impossible decision: pay for food and rent, or purchase medications and health insurance. Recent months have seen patients, students, and health professionals realize this crisis and mobilize toward a better alternative: Medicare for all. We advocate to practice in such a system, where every patient has health care. And where every patient can breathe freely.

Augie Lindmark, Vanessa Van Doren, Bryant Shuey, and Andy Hyatt are medical students the University of Minnesota, Case Western Reserve University, University of New Mexico, and Boston University, respectively, as well as board members of Physicians for a National Health Program, an organization that advocates for an improved and expanded Medicare for All health system.

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