Author Archives: jpwmd

When I started medical school in 1972, in a class of 200, eight students were women.  Times have changed.  In 2023, 54.6% of students matriculating to medical schools were women.  

The effect of the change in the physician workforce has been enormous.  Study after study documents that women are superior to men in taking patient histories, the heart of accurate diagnosis.  Female physicians on average take ten percent longer than males in office visits.  They interrupt less, deal with psychosocial issues more effectively, provide superior preventive services, and explain medical conditions better.

In a study published in The Annals of Internal Medicine in 2024, researchers examined the effects of physician gender on patients hospitalized for medical conditions.  They looked at 30-day mortality rates and readmission rates, finding that statistics for female physicians were superior in both critical categories.

Dark Clouds

Women may make excellent physicians, but they are not thriving in the medical world.  Even with the higher rates of admission to medical schools for women, they constitute only 38% of the entire physician workforce.  Part of the reason is that older doctors, who are products of medical school classes when male physicians dominated, tip the scales of the participation rates.  But there are more sinister reasons for the under representation, one of which is female physician burnout.

In an already stressful profession, and one becoming evermore pressurized by corporate policies prioritizing production over quality, female doctors shoulder greater responsibilities than men outside the workplace.  They do more of the household work and are more likely to spend more time in caregiving efforts of children and infirm parents.  Across all specialties, even taking into account hours worked per week, men earned 29% more than women.

In academic medicine, for the same amount of federally funded research and peer reviewed publications, women earned tenure at a lower rate.

The Future

The physician workforce, across most specialties, is already smaller than optimal, and projections for future needs are dire.  One avenue to meet the demand for doctors is for the medical-industrial complex to find a way to keep females in the profession.

Gambling is putting something of value on an outcome that is due to chance.  80 percent of Americans gamble in one form or another, the most common mode being playing the lottery.  But there are many other vehicles.   Most people who gamble do so recreationally, but up to six percent experience some level of problem gambling.  One to two percent are identified as pathological gamblers in the Diagnostic and Statistical Manual, which is the bible for the classification of disease.

The Business of Gambling

Gambling is big business.  Yearly lottery spending is approaching $100 billion nationally, and Commercial Gaming Revenue (casino table games, poker, race track betting, bingo, etc.) is about $70 billion.  None of this includes “off-the-books” betting, i.e., wagers between individuals.  All forms of gambling are increasing in popularity, but sports betting is enjoying a meteoric rise. 

In 2018, The Supreme Court of the US ruled that states could allow betting on sports, and now 40 states allow this manner of wagering.  In 2018, the amount of money spent for betting on sports was $.43 billion.  In 2024, that figure rose to $13.7 billion (with some estimates as high as $100 billion). 

Who Bets

Young men are the biggest sports bettors.  In this era of legalized sports gambling, 85 percent of college men wager on sports events, and the Gen Z cohort (those born from 1998 to 2012) constitutes 80 percent of all sports bettors.  The ease of betting on-line, with 24 hour access and the convenience of betting from home, abet the process.

Adverse Consequences

As documented in an article in The Journal of the American Medical Association, Internal Medicine (2025; 185 (4): 382-389), sports betting has a significant impact on the mental health of the participants.  23 percent admit to addiction, 22 percent say gambling causes financial distress, and 48 percent claim mental health issues.  

All gamblers are at risk for significant health problems, both physical and mental.  Stress related physical conditions include hypertension, sleep disorders, cardiovascular disease, and peptic ulcers.  Problem gamblers are particularly susceptible to substance misuse, low self-esteem, anxiety, depression, and suicidal ideation.  Pathological gamblers (those who suffer severe consequences from excessive gambling) have a 15 fold increase in suicide mortality compared to non-gamblers.

Adverse consequences are not limited to individual gamblers.  23 percent of partners of sports bettors, for instance, say they have had to take money from college funds to satisfy gambling debts, and 16 percent report abuse and family estrangement.  

Society in general suffers too.  For instance, the ubiquitousness of gambling threatens the integrity of sports.  The National Basketball League, for instance, has banned for life a referee and a player who fixed games.  

Signs and Symptoms of Problematic Gambling

Signs and symptoms of problematic gambling include:

• Preoccupation with gambling at the expense of family and friends
• Unsustainable financial losses
• Repeated unsuccessful attempts to quit or control gambling
• Feelings of restlessness or irritability when trying to cut down on gambling (i.e., symptoms of addiction)
• Chasing losses by trying to get back money lost by gambling
• Lying to hide the extent of gambling
• Borrowing or stealing money to support the gambling habit

Regulation

Due to the adverse effects of gambling, many advocate stronger regulation.  Even many gamblers recognize the need:  28 percent of sports bettors wish that sports betting would be illegal again.

It is unlikely to happen, however, as state governments have steadily grown dependent on revenue from gambling activity.  Four percent of the revenue for the Illinois state budget, for instance, derives from the lottery and other gambling activities.  Feckless state legislatures are unable and/or unwilling to control spending and/or raise sufficient revenue through taxation to balance budgets.  Slapping on ever higher “sin” taxes is much easier.  Equally unlikely to address the gambling problem is the federal government.  It could, for instance, limit advertising for betting vehicles, in much the same way that electronic, and then print, advertising was proscribed for tobacco products decades ago.

But there is no public discussion about the dangers of gambling, both its fiscal impact and its effect on health.  Along with other important public health problems, It should become an issue in political races.

Red Dye #3

In January of 2025, the Biden administration banned the use of Red Dye #3 in all food and drugs in the United States.  

This is a synthetic dye that is (was) used to make a cherry red coloring in many products, including candy, baked goods, frozen desserts, frosting, certain pharmaceuticals, and cosmetics.  Its use in cosmetics was banned in the 1990s with one notable exception, lipstick.  Through the years, the issue of the dye’s safety in food has experienced a checkered history.

In 1987, a toxicologist found that rats grow tumors in the thyroid gland when given huge amounts of the red dye.  Ever since, concerned scientists have petitioned the Federal Food and Drug Administration to proscribe its use entirely, citing the Delaney Clause in the Food Additives Amendment of 1958.  This provision prohibits the FDA from approving any food additive that has been found to induce cancer in humans or animals.  

The scientist who conducted the study of 1987 (industry funded) is appalled that his work has been used to discredit the use of the red dye.  He points out that his research a) studied doses of the dye that are not close to what humans get when ingesting food with the chemical, and that b) the rats in his study did not get cancer–they got benign tumors.  To this day, he asserts that Red Dye #3 is a safe additive in foods.

The federal Center for Food Safety and Applied Nutrition has agreed, stating that the risk of developing cancer from the low levels of consumed is unlikely.  

Red Dye #40 is now being used as one of the substitutes for #3.  Some studies have shown, however, an association of this additive with an adult-deficit/hyperactivity disorder (ADHD) and behavioural problems in children.

There are natural alternatives to making food look more attractive, for instance beet juice.  There are also many other synthetic dyes used for coloring food, but the safety of these substances is unknown.  Secretary of Health and Human Services, Robert F Kennedy, Jr., wants all artificial food dyes eliminated.

Fluoride

Fluoridation of public drinking water in the US began in the mid-1940s.  This has resulted in a consistent decrease in cavities by about 25%, and it has been especially helpful in populations with limited access to dental care.  75% percent of Americans now drink water that is fluoridated.  The United States Public Health Service recommends a level of fluoride in drinking water of .7 mg/liter, with 2 mg/liter being the maximum level allowable.

There is scientific consensus that water fluoridation is a safe, effective, equitable way to improve oral health.  Many assert that it is one of the most important public health interventions in the last century.  The city of Calgary in Canada stopped fluoridation in 2011, and this resulted in a dramatic increase in cavities in children.  

Nevertheless, there are naysayers, including Secretary Kennedy.  Fluoride occurs naturally in water, and in countries with high levels and no control of public water systems, fluoridation of public drinking water should not be undertaken.  In fact, a study from China associates fluoridation with low IQ, but China generally has high natural levels of fluoride in drinking water.  Studies from western scientists have not been able to replicate the China study, the methods for which are highly questionable.  

One important side effect of fluoridation is important—long term exposure to fluoride levels of 4 mg/liter or more can result in weakening of the bones.  These levels do not exist in developed countries.

Utah just became the first state to ban the use of fluoride in public water.  

What is Safe

I am not an expert in the above, and I need to rely on informed opinion about the safety of food additives and fluoridation.  But regulation of these matters has not been a paradigm of logic and consistency.  Why, for instance, did it take the FDA 38 years to implement the Delaney Clause and proscribe Red Dye #3 for all food?  And why, when the use of the dye was interdicted in cosmetics in the early 1990s, was lipstick exempted ?!

One thing seems clear:  too much of anything can be harmful.  Take water.  There is a medical condition called psychogenic polydipsia.  Afflicted individuals have an unconquerable urge to drink water–gallons and gallons per day.  These unfortunate people lack the normal physiological feedback loop that tells the brain enough is enough.  Ingesting enough water  can lower sodium levels in the blood to dangerous levels.  Seizures, coma and death occur with extremely low levels of sodium.

“Moderation in All Things” is not just a platitude.  

Dr. Mehmet Oz, in his Senate confirmation hearing regarding his nomination to be the next administrator of the Center for Medicare and Medicaid Services, said that he would prioritize uprooting fraud and abuse in healthcare.  What is fraud and abuse, how extensive is it, and what are the economic consequences?

What Is Fraud and Abuse in Healthcare?

Fraud in healthcare is defined as intentionally deceiving an insurance provider to get money for services or supplies that are not due.  Examples include: 

• – Misrepresentation of the type or level of service provided
• – Misrepresentation of the individual rendering service
• – Billing for items and services not rendered
• – Billing for items and services not medically necessary
• – Unbundling
• – Upcoding

Unbundling refers to charging for each service or item when one overall intervention is the basis for the appropriate bill.  For instance, the bill for an appendectomy includes all services and items under one rubric.  Unbundling would mean that the patient is charged for IVs, pain medications, sleeping pills, etc. individually—a much more lucrative way to bill.

Upcoding refers to billing for a service at a higher level than is justified.

Examples

Here is a sample of indictments/convictions/settlements for one week at the end of February this year regarding fraud and abuse in healthcare.

– A chiropractor in Illinois was convicted of billing for neurostimulators that were never provided.  The cost to Medicare was $1.5 million. 

– An advanced care practitioner was convicted of “providing” therapy adjuncts such as braces and physical therapy.  None of this occurred, while Medicare and Medicaid were billed $10 million.

– A counsellor was convicted of submitting fraudulent claims totalling $1.6 million.  The services were never provided.

– In September of 2021, a couple admitted to a fraud scheme that billed the government over $10 million for fake home and health services.  They were able to get personal information of recently deceased patients from obituaries.  Each received over 10 years in prison.

– A psychiatrist in Miami pleaded guilty in 2016 to multiple healthcare fraud-related counts of conspiracy.  The scheme  included entering false psychiatric diagnoses into the medical records of patients. These diagnoses resulted in more than $20 million in false disability payments.

The FBI conducted all of the above investigations, which are a small sample of fraud that was uncovered.  It typically brings ten cases of medical fraud per week to the justice system.  

What to Do

You can do your part in preventing fraud and abuse.  If your health insurance card turns up missing, call your insurer immediately.  Check your monthly statements.  If you are being billed for goods or services you never received, call your insurer.  If you are contacted (either by phone or email) about “free” medical services, it is almost certainly a scam.

Impact 

Total expenditure for health care in the US is about $1.7 trillion.  Fraud is a least $100 billion of this figure, which means that about six percent of our healthcare dollars go to bad actors.  Economists believe this figure is grossly understated.

The government hotline for possible fraud is 1880 447 8477.  The Medicare fraud hotline is 1800 633 4277.

There is no question that our youth are struggling in multiple ways, especially mental health.  This is particulary true of the Gen Z population, which consists of the children born after 1995.  Does the ubiquitous reign of technology have anything to do with it?  

Gen Z and Electronic Media

Smartphones were introduced in 2007, but did not reach current capabilities until around 2012.  These provide 24 hour internet access, on-line video games, selfie-based social media, news (real and fake) and all kinds of applications designed to beguile adolescents.  Today, 98 percent of Gen Z cohort own smartphones. 

Teens are now spending 6 to 8 hours per day looking at screens.  This includes television, which in the 1990s was two to three hours per day, but watching TV is now decreasing steadily.  The screen time statistic does not include school work.  

Due to their portability, phones constitute the bulk of the viewing time.  There are messaging apps (for example, WhatsApp), social media apps (Twitter, Instagram), and news sites, to mention a few.  These come with “alerts,” and the average teen receives 192 of them per day.  This means the phone buzzes on average every five minutes.  

Gen Z’ers spend less time in in-person contact with friends.  In 2010, they spent about 130 minutes per day with friends; in 2020, this dropped to 45 minutes.  

The percentage of students getting less than seven hours of sleep per day in 2020 rose dramatically from 2010: almost 50 percent for girls and 40 percent for boys.  

If deprived of their phones, many adolescents display classic symptoms of addiction–irritability, anxiety, and insomnia.  

Mental Health Trends

In 2008, the prevalence of an anxiety disorder among college students was 10 percent.  In 2020, it was 14 percent.  The age group from 18 to 25 (Gen Z’ers) suffered the most: the increase was 139 percent.  

The prevalence of depression among teens, fairly steady at about 13 percent for girls and 5 percent for boys before 2010, increased to about 29 percent and 11 percent, respectively, in 2021.

And the big one, suicide rates, saw an increase of 91 percent for boys in 2019 compared to 2010.  For girls, the rates increased by 167 percent over the same time period.

The inflection point on all the cited data was 2010, the year the negative statistics for those Gern Z kids started to go the wrong way.  So what happened in 2010?

Smartphones and Social Dislocation

In “The Anxious Generation” published in 2024, Jonathan Haidt lays out a grand hypothesis.  All of the negative trends cited above took off in and around 2010.  He implicates communication technology in general, but concentrates on smartphones. By 2010, the Gen Z kids  were coming of age and were becoming products of what Haidt calls the phone-based childhood. They appear to be victims of the adverse health trends cited above.

To sum it up: today’s teens are not socializing as previous generations did.  In-person social interactions are much different from chat groups.  For instance, they teach conflict resolution without having the stroke of a key handy.  Studies show that teens who spend more time on social media suffer more depression and anxiety.  It is clear that more time spent on screens deprives the young from face-to-face group activities such as sports, clubs, and religious groups.

Much of the popular media is violent, mendacious, and just plain mindless.  Haidt calls the obsession with screens the “rewiring of childhood.”  While the content is highly questionable, the sheer amount of time spent comes with opportunity costs like less time spent interacting face-to-face with other people.  Social interaction, especially during the impressionable formative years, is critical to becoming a well adjusted, productive adult.

Naysayers

Critics of Haidt’s work point out that the data show association, not causation.  Of course this is true, but no one has come up with an alternate explanation for why our youth’s mental health went south around 2010.  The Covid epidemic, with its lockdowns and school closings, did not help, but the fact is that the adverse trends started long before Covid came on the scene.

What to Do

The importance of providing healthy social activities and counselling services is critical in addressing our youth’s mental health problems.  But control of the phones could be an effective, and cheap, intervention too.  Haidt suggests that smartphones be banned from schools, that no one should have a smartphone before high school age, and that persons should be blocked from social media before the age of 16.  These are strong prescriptions, but the mental health of our young people is at stake.

In October of 2024, the Environmental Protection Agency (EPA) issued a final rule that requires drinking water systems throughout the country to identify and replace lead pipes in ten years.  What is the problem and how extensive is it?

Sources of Lead Exposure

Houses built before 1987 are a prominent source of lead exposure (chips of paint from old houses that small children eat and dust in old buildings painted with leaded paint).  Occupational exposure is also important–for instance, workers in industries that call for soldering are at risk.  Soil, especially near airports and heavy industry, have high lead content, and toys manufactured with lead machinery (especially from foreign countries) are a risk factor for lead poisoning in children.  And water from lead pipes is a significant source of lead.    

Does it Matter?

Lead is a potent neurotoxin, associated with an array of symptoms and diseases that constitute a virtual textbook of medicine.  To name a few in adults: high blood pressure, musculoskeletal pain, impaired memory, headache, abdominal pain, depression, miscarriage, premature birth, and kidney problems.

Effects on children are particularly concerning, as elevated lead levels can cause irreversible neurological symptoms, including development delay (both physical and cognitive), learning impairment, behavior disorders, deafness, and seizures.  

Research 

The National Library of Medicine recently published a review article that summarized the best research on the effects of lead exposure on the IQs of children.  Long story short:  there is no identifiable safe lead blood level (LBL).  IQ scores for children increase as lead blood levels decrease, even down to zero.  The higher the level, the greater the neurological impairment.  Similar studies have also documented the adverse effects of high lead blood levels on behavior.

Research on the effectiveness of lowering blood lead levels in adults is equally arresting.  A three percent increase in average adult IQ is correlated with a 20 percent decrease in male incarceration, poverty, high school dropout rates, and need for welfare.

Interventions

There are many ways to decrease LBLs.  For instance, soil contaminated by abandoned industry and defunct gas stations (where leaded gas can be in the soil) can be remediated.  The inhalation of dust with lead can be minimized by keeping children from playing on exposed soil.  There are effective water filters that can be fitted to faucets.  Extremely high levels of blood levels can be treated with intravenous agents that bind the lead, allowing for excretion in the urine

But Public Health interventions have been the most powerful ways to reduce the public’s exposure to lead, particularly those measures taken in the 1980s.  The last drop of leaded gasoline in the US was pumped in 1986, and leaded paint was proscribed in 1987.  The average childhood blood lead level in 1986 was 16 mcg/dL.  In 1994, it was 3.2.  The levels  have continued to fall, but, since there is no known safe level of lead in the blood, there is still work to be done.

Hence, the initiative to remove lead pipes.  Water tainted by lead is responsible for 20 percent of the lead that finds its way into the bloodstream of Americans, and even though mean blood levels in children have decreased by 95 percent since the 1980s, there is work to be done.  About 500,000 children in the US have blood lead levels greater than 3.5 mcg/d, which is the upper limit of “normal” according to the CDC. 

Cost

Of course the cost of replacing lead pipes is staggering.  Nine million homes in the US are served by lead pipes, and estimates for eliminating these pipes are about $4,700 per household.  Of But when you consider the above data about the benefits of lowering LBLs, it is clear that much of the cost, if not all of it, could be recouped with tangible societal benefit, both in terms of general health and economic impact. 

A Personal Note     

Like all primary care physicians, I have assessed many patients with complaints that defy assignment to conventional diagnostic categories.  They may complain of headaches, stomach pain, and/or diffuse muscle and joint pain.  These symptoms come and go, and these patients eventually undergo diagnostic tests (scans, endoscopies, blood tests, etc.) that do not reveal a specific cause of the complaints.  Such patients, dubbed with the title of having Somatic Symptom Disorder, often seek help from many different healthcare providers without resolution.  Anxiety and frustration are characteristic, and these patients often receive a psychiatric diagnosis. 

My research on lead poisoning has made me wonder whether I have routinely failed to identify a cause of these unfortunate  peoples’ distress that is modifiable.  Many researchers have asked the same question.  Investigations on the issue of blood levels and chronic disease are in the embryonic stage–so far nothing conclusive.                                                                                                                                                                    

In a recent blog entry (see “Blog Archive, April 12, 2024), I reported on mortality rates attributed to Covid, by voter preference for president.  The study I quoted used mortality rates from Covid infections, because that is what the source of my used.  However, I don’t think that use of raw Covid mortality data is the best way to measure deaths from the Covid virus.

Undercounting

There are many reasons to suspect that undercounting for Covid is significant.  Many African Americans have a well earned suspicion of our healthcare system (google the Tuskegee Study) and may have avoided care, even in the face of mortal consequences.  Undocumented immigrants, fearing entanglement in the web of the Immigration and Naturalization Service, may similarly avoid care.

Especially in the beginning of the pandemic, nursing homes had a powerful incentive to under-report Covid infections, for fear that their occupancy rates would plummet.   

Many county health departments simply were not up to the task of identifying and reporting Covid deaths.  Death certificates may be unreliable too.

Finally, many suicides were probably due to Covid, but not reported as such.  A person who lost his/her job and therefore the ability to care for family due to the pandemic, may have seen suicide as the only alternaive.  This is a Covid death as surely as a direct infection.

Overcounting

Overcounting is also possible.  Federal dollars flowed for the care of Covid patients, and this provided an incentive for healthcare organizations to over-report.  Hospitals, for instance, would perform Covid tests on all patients.  A patient with, say, terminal cancer could die in the hospital, succumbing completely independently of the Covid infection.  Nevertheless, this could be counted as a Covid death.

Excess Deaths

“Excess Deaths” is a statistic that overcomes these vagaries of measurement.  Actuaries track death rates over time and can predict, based on statistical trends, what the death rate in a state, for instance, will be.  A population may sustain a steady death rate of, say, 100 (the numbers are made up for purposes of illustration).  If this number bumps to 120, the excess death rate is 20 percent.   In the absence of a cataclysm like war,  an increase in the expected rate of deaths can be attributed to the pandemic.  

Excess Death Rates by Political Party

Researchers studied excess death rates by political party affiliation in Ohio and Florida from January, 2018 thru December, 2021.  Before the availability of Covid vaccines, the excess death rates between members of the two parties were similar.  For Republicans, it was 19.4%, while for Democrats, it was 18.1%.  After vaccines became available, the numbers were, respectively, 25.8 and 18.1.  In the Covid vaccine era, these figures translate to a 43% higher excess death rate in Republicans over Democrats.

To put it in concrete terms: for every 100 excess deaths in Democratic voters, there were 143 excess deaths in Republican voters.

Why the Difference?

Critics of the study cited above say there were many many factors that could account for the stark difference.  Perhaps underlying adverse health conditions could be a factor, or maybe poor access to health care.  But this ignores the inflection point that marks the availability of the Covid vaccine.  Prior to this, Democrats and Republicans died at about equal rates.

The Covid vaccine clearly made the difference, both attitudinally and in practice.  According to a Kaiser Family Foundation study in October of 2021, 23 percent of registered Republicans said they would never get the Covid vaccine.  For Democrats, the number was 4 percent.  A Brookings Institute study at the same time documented that 58 percent of Republicans had received the vaccine, while 90 percent of Democrats had gotten the vaccine.

Has the Pandemic Ended?

Yes and no.  Although the CDC has declared that the pandemic is over, the virus caused one million hospitalizations in 2023 and 75,000 deaths in the US.  

It seems people of all political persuasions have begun to forsake Covid vaccines.  Regardless of political orientation, only 28 percent of all eligible people have received the updated vaccine. The virus has undergone yet another minor mutation, but the current vaccine is effective.  Forget the politics–we should not let down our guard. 

According to news reports, Democratic presidential nominee, Kamala Harris, has abandoned her previous advocacy for “Medicare for all,” and she now supports what is basically continued enhancement of Obama’s Affordable Care Act. This got me thinking about healthcare systems in other countries, and I decided to look into Germany’s highly regarded system.

As in all western European countries, 100 percent of the population is covered by healthcare.  Health insurance in Germany is mandatory.  It is financed by a combination of employer/employee contributions, and there is also a monthly premium for individuals based on income.  The government subsidizes those without the means to pay the premiums and failure to sign up for insurance results in a fine.  With the exception of small co-pays for certain services, no money passes between patients and providers.  Billing is strictly between the government and providers.

There is no equivalent to Medicare or Medicaid.  There are about 100 private companies that provide insurance options, and they are required by law to offer a basic package of benefits.  In addition to all the areas that are commonly covered by insurers in the US, German plans include dental care and hearing aids.  Long term care (i.e., nursing homes) is also covered.  Every patient can access care from any provider at any time, without the bother of determining who is “in plan.”   All premiums are uniform–there is no increased cost, for instance, for age or medical conditions.  In fact, there is no penalty for “pre-existing conditions.”

About 90 percent of the population enjoys the public health plan, while 10 percent can opt for private health insurance.  The latter is more expensive, as providers charge what they will.  Participants qualify for benefits such as private hospitals with amenities like private rooms.  However, they basically pay double for insurance, as they are contributing to the national insurance through employment, even though they are not using the public system.

Cost/Quality

According to data from the United Nations, the cost of medical care in Germany in 2022 was $8,010 per capita.  This is a bit more expensive than other countries in western Europe, but the cost in the United States was $12,555.  As a percentage of Gross Domestic Product, the cost in Germany is 12.6 percent, while in the US it is 16.6 percent.

Ratings of the quality of healthcare systems measure such parameters as infant mortality, overall mortality, health outcomes, risk factors, access to care, administrative efficiency, affordability, and many more.  In an analysis by the Commonwealth Fund, which looked at 11 developed countries, Germany was 5th and the US was last… by a lot (Norway was the best).

Going Forward

Healthcare in the United States remains a political hot potato, and the major parties are divided about strategy to improve healthcare.  The Democrats want universality and the Republicans tend to want to promote the private sector as the means to improve the system.  Although the German system is imperfect (costs are high and rising, for instance), its approach seems to offer both.  It puts healthcare squarely in the private sector, while guaranteeing provision of a certain package of benefits.  Competition among the insurers provides, at least theoretically, price control, and the debate about whom to cover becomes moot in a universal coverage system.  

The US system is deficient in quality and excessive in cost, factors that everyone agrees upon.  A system such as Germany’s should be examined.