The Democratic debate is less than a week away, and it’s likely that health care will once again take center stage. Once again, the candidates will spar over the best way to achieve universal coverage. Once again, the progressives will talk up the benefits of “Medicare For All” while the moderates attack it for its high cost and lack of choice. Just like the last debate. And the one before.

But it’s not the repetitiveness of the health care debate that bothers me. As a medical student, what bothers me is that the current health care debate is myopically focused on health insurance.

Although health insurance coverage is important, it’s only part of the picture. If the goal of our health care system is to keep Americans healthy, insurance will only get us so far. Health is about much more than access to health care.

Asthma triggers when you’re homeless

Take the case of a patient I helped treat this past summer, a young man in his early 20s who came into the emergency department experiencing severe shortness of breath. I could hear him wheezing before I even walked into the room.

He was sitting on the stretcher, breathing rapidly, and leaning forward with his hands on his knees — the classic “tripod” position signifying respiratory distress. After the resident physician and I determined he was having an asthma attack, we controlled his symptoms with steroids and inhalers and monitored him until he improved.

As I was preparing to discharge the patient, I briefed him on some of the asthma triggers he should avoid. When I advised him to keep the windows closed to minimize his exposure to pollen, he told me that the shelter where he was staying didn’t have air conditioning. It was 83 degrees outside that day.

Health insurance couldn’t prevent his next asthma attack. He needed a better and more stable housing situation.

Food deserts and no ride to the doctor

The same was true for a second patient of mine who was admitted to the hospital with diabetic ketoacidosis, a life-threatening complication of diabetes resulting from poor blood sugar control. After he recovered, we discharged him home to a food desert, a neighborhood where grocery stores and fresh-food markets are scarce and where following a low-carbohydrate diet is next to impossible. Health insurance cannot solve the food insecurity in his community.

Nor could health insurance enable a third patient of mine — who’d had vascular surgery to re-open a blocked artery in his leg — to return for his follow-up visit. Had he done so, we would have caught his post-operative infection early. As it happened, however, he had no way of traveling the 15 miles from his home to our clinic, and his infection worsened to the point that we had to amputate two of his toes. Health insurance didn’t address his transportation barriers.

Fortunately, all three patients were insured. Indeed, I’m grateful to attend medical school in Massachusetts, which has achieved near universal health insurance coverage. But sometimes insurance isn’t enough. I constantly see cases like these in which acute health problems arise due to factors seemingly unrelated to medicine. Universal coverage, while a worthy goal, does not translate into universal health.

Who will fix holes in the social safety net?

A recent study that rated U.S. counties based on health outcomes found that access to medical care accounted for only 20 percent of a county’s score. The other 80 percent was more readily attributable to social and economic factors like the ones affecting my patients, including housing instability, food insecurity, and access to transportation.

The health care dialogue in this political race has been dominated by the notion that we need to cover everyone, a principle I fully support. But even if we achieve that, it will only get us a fraction of the way to our goal of better health for all Americans. The German health care system is widely praised for its universal coverage, robust primary care, and low out-of-pocket costs for medical care. But it is nonetheless plagued with health disparities. In some cities, life expectancies of neighboring communities differ by up to 13 years.

To neglect these social factors in our public discourse on health care would be a mistake, not only because they are important to public health but also because policymakers are often better equipped to tackle social factors than they are medical ones. Evidence suggests that providing stable housing to homeless populations in urban areas, for instance, contributes to significantly reduced mortality.

Insurance coverage is a critical determinant of health. We should discuss it. But candidates for president should also discuss their plans to strengthen communities by addressing homelessness, food insecurity, and the other social factors that underpin America’s health gap.

Thus far, these issues have received scant attention in the Democratic primary race and in the larger political dialogue about health care. We need to broaden the conversation from a narrow discussion of health insurance to a holistic conversation about health.

Suhas Gondi is a third-year medical student at Harvard Medical School. A version of this essay originally appeared in Undark, the online science magazine.

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“Don’t read The House of God,” one of my professors told me in my first year of medical school.

He was talking about Samuel Shem’s 1978 novel about medical residency, an infamous book whose legacy still looms large in academic medicine. Shem — the pen name of psychiatrist Stephen Bergman — wrote it about his training at Harvard’s Beth Israel Hospital (which ultimately became Beth Israel Deaconess Medical Center) in Boston.

My professor told me not to read it, I imagine, because it’s a deeply cynical book and perhaps he hoped to preserve my idealism. Even though it has been more than 40 years since its publication, doctors today still debate whether it deserves its place in the canon of medical literature.

The novel follows Dr. Roy Basch, a fictional version of Shem, and his fellow residents during the first year of their medical training. They learn to deflect responsibility for challenging patients, put lies in their patients’ medical records and conduct romantic affairs with the nursing staff.

Basch’s friends even coin a term that is still in wide use in real hospitals today: Elderly patients with a long list of chronic conditions are still sometimes called “gomers,” which stands for “Get Out of My Emergency Room.”

Like any banned book, The House of God piqued my curiosity, and I finally read it this past year. I’m a family physician and a little over a year out of training, and I read it at the perfect time.

I got all the inside jokes about residency — and many were laugh-out-loud funny — but I am now far enough removed that the cynicism felt like satire rather than reality.

The House of God also felt dated. Basch and his cohort — who were, notably, all men, although not all white — didn’t have electronic medical records or hospital mergers to contend with. They wrote their notes about patients in paper charts. And it was almost quaint how much time the doctors spent chatting with patients in their hospital rooms.

It couldn’t be more different from my experience as a resident in the 21st century, which was deeply influenced by technology. There’s research to suggest that my cohort of medical residents spent about a third of our working hours looking at a computer — 112 of about 320 working hours a month.

In The House of God, set several decades before I set foot in a hospital, where were the smartphones? Where was the talk of RVUs — relative value units, a tool used by Medicare to pay for different medical services — or the push to squeeze more patients into each day?

That’s where Shem’s new book comes in. Man’s 4th Best Hospital is the fictional sequel to The House of God, and Basch and the gang are back together to fight against corporate medicine. This time the novel is set in a present-day academic medical center, and almost every doctor-patient interaction has been corrupted by greed and distracting technology.

Basch’s team has added a few more female physicians to its ranks, and together they battle a behemoth of an electronic medical record system. The hospital administrators in Shem’s latest book pressure the doctors to spend less time with every patient.

If The House of God is the great medical novel of the generation of physicians who came before me, perhaps Man’s 4th Best Hospital is the book for my cohort. It still has Shem’s zany brand of humor, but it also takes a hard look at forces that threaten the integrity of modern health care.

I spoke with Shem about Man’s 4th Best Hospital (which hit bookstores this week) and about his hopes for the future of medicine.

This interview has been edited for clarity and length.

The protagonist in Man’s 4th Best Hospital, Dr. Roy Basch, doesn’t have a smartphone. I hear you don’t either. Why not?

If I had a smartphone, I would not be able to write any other novels. I have a bit of an addictive personality. I’d just be in it all the time. … I’ve got a flip phone. You can text me, but it has to be in the form of a question. I have this alphabetical keyboard. You either get an “OK” or an “N-O.”

A big theme in the novel is that technology has the potential to undermine the doctor-patient relationship. What made you want to focus on this?

I got a call out of the blue five years ago from NYU medical school. They said, “Do you want to be a professor at NYU med?” And I said, “What? Why?” And they said, “We want you to teach.” When I first got there, because I had been out of medicine [and hadn’t practiced since 1994], I figured, “Oh, I’ll look into what’s going on.” And I spent a night at Bellevue.

On the one hand, it’s absolutely amazing what medicine can do now. I remember I had a patient in The House of God [in the 1970s] with multiple myeloma. And that was a death sentence. We came in; we did the biopsy. He was dead. He was going to be dead. And that was that. Now it’s curable.

At Bellevue, I saw the magnificence of modern medicine. But like someone from Mars coming in and looking at this fresh, I immediately grasped the issues of money and effects of screens — computers’ and smartphones’.

And it just blew me away. It blew me away: the grandeur of medicine now and the horrific things that are happening to people who are really, sincerely, with love, trying to practice it. They are crunched, by being at the mercy of the financially focused system and technology.

In Man’s 4th Best Hospital, there’s a fair amount of nostalgia for the “good old days” of medicine in the 1960s and 1970s, before electronic medical records. What was better in that era?

If you ask doctors of my generation, “Why did you go into medicine?” they say, “I love the work. I really want to do good for people. I’m respected in the community, and I’ll make enough money.” Now: … “I want to have a good lifestyle.” Because you can’t make a ton of money in medicine anymore. You don’t have the respect of your community anymore. They may not even know much about you in a community because of all these [hospital] consolidations.

Do you think anything in medicine has gotten better?

The danger of isolation and the danger of being in a hierarchical system — students now are protected a lot more from that. When I was in training, interns were just so incredibly exhausted that they started doing really stupid things to themselves and patients. The atmosphere of training, by and large in most specialties, is much better.

You wrote an essay in 2002 titled “Fiction as Resistance,” about the power of novels to help make political and cultural change. What kind of resistance today can help fix American health care?

When somebody falls down, up onstage at a theater, do you ever hear the call go out, “Is there an insurance executive in the house?” No. If there are no doctors practicing medicine, there’s no health care. Doctors have to do something they have almost never done: They have to stick together. We have to stick together for what we want, in terms of the kind of health care we want to deliver, and to free ourselves from this computer mess that is driving everybody crazy, literally crazy.

Doctors don’t have a great track record of political activism, and only about half of physicians voted in recent general elections. What do you think might inspire more doctors to speak out?

Look at the difference between nurses and doctors. Nurses have great unions, powerful unions. They almost always win.

Doctors have never, ever formed anything like what the nurses have in terms of groups or unions. And that’s a big problem. So doctors somehow have to find a way — and under pressure, we might — to stick together. Doctors have to make an alliance with nurses, and other health care workers, and patients. That’s a solid group of people representing themselves in terms of what we think is good health care.

The profession we love has been taken over, with us sitting there in front of screens all day, doing data entry in a computer factory.

Health care is a big issue for the upcoming election. What kind of changes are you hoping we’ll see?

There will be some kind of national health care system within five years. … You know, America thinks it has to invent things all over again all the time. Look at Australia. Look at France. Look at Canada. They have national systems, and they also have private insurance. Don’t get rid of insurance.

The two biggest subjects for the election are health care and health care. … The bad news is, it’s really hard to get done. The good news is, I think it’s inevitable. The good news is, it’s so bad it can’t go on.

One of the major criticisms of The House of God is that it’s sexist. It seems like your hero, Dr. Basch, has gotten a little more enlightened by the time of Man’s 4th Best Hospital. Does this reflect a change you’ve also experienced personally?

I was roundly criticized for the way women were seen in The House of God.

I remember the first rotation I had as a medical student at Harvard med was at Beth Israel, doing surgery. It got to be late at night, and I was trailing the surgeon around, and he went into the on-call room. There was a bunk bed there, and he started getting ready to go to bed. And I said, “Well, I’ll take the top bunk.” And he said, “You can’t sleep here.” So I left, and in walked a nurse. I was shocked.

Things have changed, and I am very, very glad. I don’t know if it seems conscious — I was very pleased to have total gender equity in the Fat Man Clinic [where the characters in Man’s 4th Best Hospital work] by the end of the book.

What made you feel like it was time to update The House of God?

I write to point out injustice as I see it, to resist injustice, and the danger of isolation, and the healing power of good connection. … We can help our patients to get better — but nobody has time to make the human connection to go along with getting them better.

Mara Gordon is a family physician in Camden, N.J., and a contributor to NPR. You can follow her on Twitter: @MaraGordonMD.

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