We are looking at a population that is the least likely to be able to obtain insurance and the most likely to benefit from it. Since the majority of states have taken the opportunity to expand Medicaid, data now exist to show clearly the predictably favorable cost-benefit results. I was glad to see the panel had done the research and was able to very clearly present that data. If there were any semireasonable concerns, surely these were dispelled via previously published editorials in the Tulsa World.

Although from my standpoint, Medicaid expansion would be a small step forward, it would be a great step for those whose very lives may be saved by way of receiving timely medical care.

Increasingly, we are going to be faced with proposals to “fix” our health care system; therefore, it seems timely to pursue a dialogue, defined by certain parameters, as to what in the world this actually means. My own interest in health care began quite early in life when I found myself in a situation most gently described as rural poverty and having a family characterized by dysfunction with a generous dose of ignorance. My mother had seven children, four of whom were to die, three of these being possibly preventable deaths had there been access to medical care. I was the youngest and only one born in a hospital. The war had started, and my father had real employment for the first time. At least two years prior to my birth, my mother developed multiple sclerosis so that I never saw her walk unaided. She never knew the cause of her problems until dying of cervical cancer some 18 years later. Yes, perhaps the world’s most preventible cancer, but only if one has access to primary health care.

So you can see I have reasons to be very opinionated regarding this subject.

In 1964, I found myself in medical school in St. Louis and discovered the city had two giant city hospitals that provided medical care to all residents. Although by that time they were integrated, one had been built for African American residents; the other had been built for white residents. Both provided very good care as well as great teaching opportunities. My initial conclusion was although clearly the best way to obtain medical care was to be in a position to purchase it, the alternative would be to live in an urban area where the governing body actually cared about the residents.

In 1971, I entered the University of California-Berkley Public Health School, where the need to “fix” our system was an omnipresent aspect of nearly every discussion. Now nearly 50 years later, we are still debating whether it is time to attempt increasingly needed action. This is somewhat different than the closely related question as to whether everyone deserves to receive quality healthcare.

Please allow me to explain. We currently spend nearly 18% of our gross national product on health care. This is approximately 50% more than any other nation, developed, undeveloped or in-between. Our outcome measures have fallen to approximately 35th. In other words, we spend much more than others and achieve relatively unsatisfactory results.

These two facts define the problem that needs to be fixed. In 1971, we were all “betting” on when this would be accomplished. I bet that it would happen when health care costs reached 24% to 25% of the gross national product. More cynical students predicted a higher level while the more optimistic predicted a lower level. I stand by my prediction.

I believe that it was 2009 when I was invited to meet with a group of physicians and President Obama to discuss the proposed Affordable Care Act. He did not try to fool us. He candidly acknowledged that it was not a proposal to “fix” the health care system, but rather a way to provide health insurance coverage for nearly everyone. I cannot adequately express how impressed we were regarding his knowledge and understanding of our health care system and his rationale in terms of his proposal being the best that could be achieved.

I told him that I should be appointed to be his Secretary of Poverty and Ignorance since I understood the dynamic interface between the two. President Obama assured me that he too understood that relationship.

I really had mixed feelings. On the one hand, I felt that the measure would significantly delay any move to actually fix our system. On the other hand, I had to support a plan that, if fully implemented, would provide better lives for millions of people and directly save the lives of thousands while indirectly saving tens of thousands.

How could we “fix” the health care system? One would logically start by looking at the systems in the approximately 34 countries outperforming us. I am sure that one would find about 34 different models to analyze with the only universal characteristic being that they provide quality health care to everyone.

Can we afford such a program? Of course we can. We currently spend about $3.6 trillion on health care every year. Any plausible proposed model would not be projected to cost more, although certainly the means of payment would be different. As a matter of fact, many proposed models will likely claim to cost less; however, I have little faith in the likelihood that any program would actually save money via being more efficient as well as effective.

As to the question of whether we should provide quality health care for everyone, that is a matter of opinion, belief, values and perhaps even spiritual reference. In other words, a fascinating subject that would provide essentially never ending discussion with endless anecdotes.

In the meantime, perhaps we can actually focus on fixing our system, and hopefully I will lose my bet!

Blaine M. Sayre, M.D., M.P.H., F.A.A.P.