We Cannot Achieve Quality in the Absence of Equity
I strongly believe the road to quality care and the more effective use of health care dollars is firmly rooted in the elimination of racial and ethnic health care disparities. The staggering rates of health disparities in the U.S. stand as a bellwether for quality of medical care. African Americans receive poorer quality health care than whites for about two-thirds of current measures, while Hispanics receive lower quality care than non-Hispanic whites for half of quality measures. We cannot achieve quality in the absence of equity.
To achieve quality care and better use of our health care dollars, we must build a system based on improved data collection and analysis, greater public accountability, increased use of technology and a population-based system of evaluation. For far too long, we have allowed and relied upon the medical profession and our health care institutions to monitor and assess quality while hiding behind the threat of medical malpractice, the highly technical nature of medical care and the cloak of “patient confidentiality.” We have only scratched the surface of what is needed to bring about real quality improvement, reduce medical errors and eliminate health care disparities. In the absence of public policy, the financial interest of insurance companies should drive quality improvement. And, indeed, many insurance companies and even Medicare are moving to a “pay-for-performance” model. But not only are these new payment schemes limited in their effectiveness, they generate a whole new set of problems for patients and providers alike and do little to address the issue of health care disparities.
Data collection and public reporting are at a very basic level, and the interval between delivery of care and actual reporting is far too great. The current “pay-for-performance” scheme can easily lead to under-reporting, under-utilization and “creaming” of patients, leaving chronically ill patients disenfranchised. The incentives need to be aligned with: (1) accurate and timely reporting of an expanded data set including health status and demographic information; (2) improvements in health status and the management of chronic disease; (3) the development and use of technology to document, report and guide the delivery of medical treatment; and (4) reducing disparities in the quality of health care and health outcomes for racial and ethnic populations.
Payment policies should help create incentives for not only working with underserved and chronically ill patients, but support the use of evidence-based and culturally-based best practices in the treatment of illness and disease and the elimination of health care disparities. Little if any data collection and reporting are done based on race, ethnicity or income, thereby masking inequalities in care. Quality improvement efforts should drive data collection and take into account the challenges and needs of underserved communities and reward efforts that reduce disparities and improve patient outcomes. While the initial investment may be high, the improvements in patient care and safety along with the long-term financial savings in health care costs are clear.
Getting to GDP+1
I am envious of my colleagues on this site who have the relatively easy job of describing the pressing need to achieve universal coverage in the United States and discussing approaches to achieving that goal. I characterize their job as relatively easy, although the failure to date to accomplish this goal speaks volumes to the difficulties. The problems in achieving universal coverage are primarily political. With the exception of Massachusetts (which financed coverage primarily with federal dollars), we have yet to assemble 51% of a legislature to vote for getting almost everyone covered, although we came close in Sacramento in 2007, and many of us have high hopes for action in Washington DC this year.
In contrast to the story on coverage, the problems in figuring out how to reduce the rate of growth in health spending are both technical and political. There is fairly wide agreement that health spending growth needs to be reduced. Over the past 40 years, health expenditures have increased at approximately 2.4% per year faster than the rate of growth of the Gross Domestic Product (that is, at GDP+2.4). If health expenditures were to continue to increase at GDP+2.4, the fraction of our income that is devoted to health care would double over the next 30 years – from approximately 16.5% in 2008 to over 33% in 2037. Some might argue that we can afford to spend that much of our income on health care, but it is impossible for me to imagine either the public or private sector financing arrangements that could support that level of spending.
Currently, the federal and state (and, to a minor extent, local) governments pay about one-half of the nation’s health bill – approximately 8% of GDP. If the 50-50 ratio of public to private spending were to remain constant, an increase in health spending to 33% of GDP would require an increase in tax revenues of about 8% of GDP to support it. This would be possible only if we were willing to elect politicians who pledged: ‘Spending on health care is very important, and I promise that if you elect me I will work hard to continually increase your taxes as long as you are alive to support this valuable public function.’ The political landscape has changed a lot in the past year, but I don’t think a politician could win on that platform.
And rapid health expenditure increases on the private side are no more sustainable than in the public sector. The average family health insurance premium in California in 2008 for employer-sponsored insurance was approximately $13,000. That amount is already unaffordable for a large number of moderate-income families. At GDP+2.4, that premium will approximately double (in today’s dollars) over the next 30 years, making health insurance, and most health care, unaffordable for the majority of workers and their families.
Health expenditures have been increasing more quickly than the rest of the economy primarily because of the rapid adoption and diffusion of new technology. Slowing health expenditure growth requires, in the medium to long term, some slowdown in the rate of diffusion of new technology. That is a potentially scary prospect, raising the specter that slower health expenditure growth will deny us the health benefits that we might achieve if we let technology diffuse more rapidly. The reassuring news is that most countries in Europe have diffused technology somewhat more slowly than we have in the US, have had somewhat slower growth in health expenditures over the past 40 years than we have in the US, but have achieved greater gains in life expectancy and larger reductions in infant mortality than we have in the US. If done halfway intelligently, we should be able to slow health expenditure and technology growth while continuing to enjoy gains in quality and quantity of life.
While there is widespread agreement that something must be done to move us closer to GDP+1, there is almost no serious discussion of ideas that would get us there. The strategies commonly mentioned as methods for reducing expenditure growth – investment in health information technology; investment in comparative effectiveness research, investment in health promotion and disease prevention; greater implementation of pay for performance; greater transparency in pricing; increased use of disease management and high cost case management; establishment of medical homes; reduction in administrative costs; and malpractice reform — may be good ideas and might well lead to improvements in quality and efficiency, but are not likely, by themselves, to substantially slow the adoption or diffusion of new technology, or to move us much closer to GDP+1. I will discuss in my next post some of the ideas that might actually move us towards GDP+1.
Achieving Health Equity through Health in All Policies
The California Pan-Ethnic Health Network (CPEHN) works to ensure that all Californians have access to quality health care and can live healthy lives. We gather the strength of communities of color to build a united and powerful voice in health advocacy.
CPEHN was founded in the early 1990s in the era of national health care reform. Fifteen years later, we find ourselves, once again, engaged in the same debates. Unfortunately, the health of our nation has only gotten worse during these fifteen years, with rates of chronic conditions such as obesity, diabetes, high blood pressure, and asthma ever increasing. This is especially true among our diverse communities. We know now, more than ever, that the way we are approaching health care in the United States is neither strategic nor sustainable, and does not make us a healthier nation. We know now that we have to do things differently.
It is time we put significant investments in primary prevention. Health is fundamental to our happiness and productivity, and our approach needs to involve more than just health care. Our well-being is about the neighborhoods we live in, the opportunities we are afforded, and the actions of our government. National health care reform efforts can begin to achieve health equity by including these three simple approaches:
• Incorporate health in all policies. In the past, decisions about issues that have big impacts on community health – for example, transportation, land use, agricultural policy, housing – have been made with little consideration as to whether the end result would be good for our health. The only way that our housing conditions, transportation infrastructure, food options and air quality will promote our health is if we analyze these policies through a health lens. Just as each policy goes through an appropriations process in the legislature, each policy should go through a health analysis. Health, along with education, transportation, environmental, agriculture, labor and housing agencies should be required to work together to identify the health impact of their policies, which will enable them to develop policies that better promote health, or mitigate negative health effects. This is particularly important to ensure that policy decisions do not continue to adversely impact communities that already suffer from poor health. For example, by conducting a Health Impact Assessment, researchers found that providing paid sick days for all workers is not just a labor issue, it would have public health benefits by reducing the spread of flu and protecting the public from diseases carried by sick workers in restaurants.
• Revise the federal poverty level guidelines. The current federal poverty levels are outdated and do not take into account modern realities. These levels are used in most of our government’s policies to determine who is eligible to receive important services such as food stamps, cash assistance and health insurance. A 2007 report by the California Budget Project ([PDF] Making Ends Meet: How Much Does It Cost to Raise a Family in California?) found that a single adult in California requires an annual income of $28,336 – more than double the amount of the federal poverty line – to cover basic expenses. The federal poverty level needs to reflect current basic needs and geographic differences.
• Collect and analyze data by race, ethnicity, and language. All federal and state agencies, health delivery systems and public health departments need to collect and analyze data by race, ethnicity and language. This information is critical to understanding the population served and the underlying systemic factors impacting health, targeting limited resources most cost-effectively and developing culturally appropriate interventions. Without this data, we will continue to develop one-size-fits-all approaches that contribute to racial and ethnic disparities.
The current health care reform effort is our opportunity to take a comprehensive approach to health – from creating healthier places where we live and work, to equal access to quality care. Let’s make it a reality.
Limiting Treatment to Those Who Need It
The United States will produce more than $14 trillion worth of goods and services this year—truly an astonishing amount. But equally astonishing is that one out of every six of these dollars will go to health care. By comparison, in 1960 Americans spent only $1 out of every $20 on health care.
This ever-increasing share of national output going to health care is the source of much hand-wringing by policy makers. They worry that we cannot afford to spend so much, and that our national output will suffer as a result.
They have it backwards.
Part of the reason we spend so much more on health care is because we are wealthier. As incomes rise, there is only so much value we can get from adding more square footage to our houses, putting more horsepower in our cars or buying finer wine. What really makes a rich society happy is to have more time to enjoy all these goods and services. So we spend more on health care so that we can live longer and healthier lives to enjoy the fruits of all our labor.
Put another way, if you had the choice between buying 1960s medicine at 1960s prices, or today’s medicine at today’s prices, which would you prefer?
This doesn’t mean we couldn’t spend our money better. The primary driver of rising health care costs has been medical technologies. We continue to develop expensive treatments and, equally importantly, apply them to broader swaths of the population. For example, the development of magnetic resonance imaging (MRI) has revolutionized our ability to diagnosis brain tumors and other serious musculoskeletal problems. But when patients with insurance clamor for an MRI every time they sprain their knee, that raises costs for all of us. It also is what makes insurance premiums unaffordable for many Americans.
So, going forward, the policy goal should be to get the right drugs and treatments to the patients who need it. But it also sometimes means withholding treatment in cases where it might do only very little good.
There are two distinct ways to ration medical technology. Here the term ‘ration’ is used in the economic sense, not pejoratively. For example, we rely on the private marketplace to ration televisions. Suppliers who can sell televisions more cheaply are rewarded with more market share, and consumers decide what they want to buy. This is downstream rationing—and the key is that we rely on prices to determine who gets a good or service.
The problem with downstream rationing in health care is that insurance completely insulates the patient from the full price. There is little incentive for the supplier to lower costs. There are ways to make the patient more sensitive to price. For example, we could restructure health benefits so that consumers are asked to pay more out-of-pocket for services providing little clinical benefit. Patients who insist on an MRI for their ankle sprain will think twice if they have to pay several hundred dollars for it.
The alternative approach is upstream rationing—that is, the government decides what makes it to the market in the first place. We already do this a lot in health care. The Food and Drug Administration is responsible for approving many new treatments and medical devices. Right now they make this decision solely on the basis of medical necessity. So if your drug is somewhat better than standard care, it gets approved regardless of whether it costs $100 or $200,000 per year.
The FDA could tilt the playing field to encourage cost savings. This could be done by offering expedited approval—and immediate coverage by Medicare—if the manufacturer can demonstrate that its treatment will reduce overall health care costs. This judgment would be made by independent experts, as the FDA does now, and would be monitored through post-marketing studies. Such decisions are made routinely in other countries with national health systems.
Unfortunately, upstream rationing sounds better in theory than practice. It is hard to collect to data on outcomes, and it is even harder to use it to make policy decisions. Mainly, this is because for any medical treatment, there is usually a population who gets enormous benefit, and then there is a (usually much larger) population for whom the benefits are unclear.
This is the promise of comparative effectiveness—to try and identify the relative value of treatments. The data could then be used for both upstream rationing (through the FDA) or downstream (by insurers when they decide how much patients have to pay).
While this sounds good, whether the government can implement comparative effectiveness effectively is open to debate. We are not very good at estimating the health care benefits (and even costs) for many patient populations, and the thought of using the current methods to estimate gains should give everyone pause.
Eliminating Fee-For-Service Should Be a Given
Our health care system pays providers for the number of treatments and procedures they provide, and pays more for using expensive technology or surgical interventions. It is neither designed to reward better quality, care coordination or prevention, nor to encourage patients to get the right care at the right time. While there are literally hundreds of efforts across the country to reform payments, without Medicare’s leadership these efforts will be too small and run the risk of distracting instead of focusing health care providers on delivering better care.
Moving away from fee-for-service payments should be a “given” as we reform payment. We need a compass to make sure that what we are not just moving away from a toxic payment system, but moving towards payments that promote higher quality and more affordable care. Recently, a coalition of consumers, employers, labor and providers have come together because of their agreement on the need to transform the payment system. This group – the Center for Payment Reform – has established six core principles that should guide both public and private payment policies:
1. Reward the delivery of quality, cost-effective and affordable care
2. Encourage and reward patient-centered care that coordinates services across the spectrum of health care providers and care settings – which must include increasing payments for primary care, while reducing payments and generating savings in other areas
3. Foster alignment between public and private health care sectors – meaning we must recognize that it is an entire health care system that must be made higher quality and more affordable, not either the public or private sectors
4. Make decisions about payment using independent processes – decisions about payments need to be steered by those who receive and pay for care, not just by those who deliver services
5. Reduce expenditures on administrative and other processes
6. Balance urgency to implement changes against the need to have realistic goals and timelines
Using these principles as guidance, we must design payment systems to reward providers for giving the right care at the right time and encourage patients to be actively engaged in their care. Employers, consumers and providers needs to be engaged in the coming months to be sure that we are indeed following these principles.
It’s Not a Question of How, But of Political Will
Thank you for your kind invitation to participate in this dialogue. We [Insure the Uninsured Project] support all approaches that will increase coverage of the uninsured so that all 6.5 million uninsured Californians have coverage for basic health services. We don’t pick sides. We support individual mandates, employer mandates, single payor and incremental reforms to cover all children, working families and individuals who lack coverage. We are all one lost job or one serious illness or accident away from becoming uninsured.
The big question is how do we get from here (6.5 growing to 7 million uninsured) to there (coverage for everyone) in the midst a severe economic downturn that highlights the need for major reforms yet hamstrings our financial capacity to pay for care. Starting locally, programs like Healthy San Francisco need to be spread. They bring together clinics, public hospitals and public health plans into an organized system—an organized safety net delivery system for the uninsured. At a minimum, these efforts can provide a primary care doctor, an organized delivery system and electronic medical records.
California needs to ask the Obama Administration for a broad federal waiver that would do the following. Through this waiver, we could offer coverage to up to 3 million of our 6.5 million uninsured.
1. Consolidate all our state and local programs for low income Californians into a single system. This will include linking county and state physical and mental health care programs and covering all the uninsured with incomes up to 200% of the Federal Poverty level ($40,000 for a family of four).
2. Match all our state and local funds.
3. Tax hospitals and use the proceeds to increase their Medi-Cal rates to Medicare levels, and use DRGs (diagnosis related grouping) and pay for performance to get hospitals’ payment and quality incentives coordinated in a proper fashion. This has already been done successfully in several states, beginning in Massachusetts over 25 years ago.
4. Require that everyone in the state’s public programs enroll in the managed care plan of his or her choice. It has worked better than fee for service medicine for families; we will need specialty managed care and risk adjustments and special higher cap rates for those with certain kinds of medical conditions. On Lok and the Health Plan of San Mateo are excellent local models.
5. Adopt an interoperable basic electronic health record (EHR) system and require that every licensed provider and each health plan in the state transition to it. Kaiser’s EHR has already shown promising results.
At the federal level, my choices for health reform are whatever form of universal coverage President Obama and a bi-partisan sixty vote Senate majority can agree on. Let’s be clear from the start that we are going to need a bi-partisan Senate vote with support from both business and labor.
Personally, I prefer the ideas in the Senators Wyden and Bennett bill, an exemplary bi-partisan proposal. Wyden-Bennett covers everyone for a basic set of benefits, with benefits similar to FEHBP (Federal Employees Health Benefits Plan). It shifts the employer role from paying premiums to paying a tax. An individual pays a share of their premium and picks a private plan, a doctor and the coverage he or she wants; there are subsidies for those who cannot afford coverage. Everyone must have coverage—there is an individual mandate. There are regional or state based exchanges through which you buy your coverage on a guaranteed issue basis; you cannot be denied coverage regardless of your medical condition. If you want more extensive coverage, you, the consumer, pay the extra cost.
I prefer this approach for a few reasons. First, it avoids all the intersection issues and resulting administrative expenses between public and private coverage, between individual and employer coverage, and between four major types of public coverage. Think of your friend who lost a job, had COBRA coverage until it ran out and then tried to buy individual coverage and finally applied for public coverage for his family. Second, there are lots of workers who do not fit the mold of the full-time, full-year employee of a large company for which our employment-based system is best designed. Think of your family members now working several part time jobs to get by. Third, it redistributes the $300 billion in federal and state tax subsidies for private coverage to those employees and individuals that need them most. These tax subsidies are concentrated with high wage earners in high income tax brackets – not the lower wage working families who have the biggest affordability challenge with the costs of coverage.
My biggest concern is cost containment to assure long-term affordability. We need to eliminate the 30% or more of utilization that is inappropriate and wasting money. We need to get rid of the over-priced and poor quality care treatments and procedures and reduce the far higher than needed administrative costs for plans and providers. These costs need to be removed from taxpayer’s back and from corporate books so the economy, the budget deficit and job creation can rebound.
This is doable but is hardly going to be easy. It’s more a function of political will than of how to do it. We’ve had it pretty close to right a couple of times in California, but the big mystery remains: how do you do health reform right and in a way that the public and many of the stakeholders will accept and support? As a citizen, I’m going to be supportive of whatever President Obama and Congress come up with, and hope all of you will send them your good ideas and be supportive of the reform that emerges this summer. We might not reach perfection, but we’ll get something much better than what we have.
Mandatory Health Insurance is Not Universal Choice
“Covering the uninsured” through more government power is a misplaced priority. It gives politicians, instead of patients, control of health-care dollars. Nevertheless, many Americans understandably view the fact that the U.S. is the only developed country that does not have so-called “universal” coverage as a national disgrace. Furthermore, many believe that the uninsured delay primary care until their illnesses worsen and they show up at emergency rooms for wildly expensive — but unpaid – treatment, imposing an extra burden on hospitals, the privately insured and taxpayers.
However, an analysis of national health spending for 2000 showed that the uninsured incurred less than 7 percent of all medical-care expenses, and significantly fewer of them were likely to present at an emergency room than either the privately insured or those dependent on government-run programs, such as Medicaid. In 2003, 1.8 million insured kids visited California ERs, versus only 80,000 uninsured kids. The claim that 4 percent of the kids who present at ERs are somehow driving hospitals to the financial brink is implausible on its face. On top of this, almost two thirds of uninsured California kids are eligible for government-run plans but not enrolled!
“Universal” health care in other countries is less a reality than a government slogan: Over one in six Canadians have no access to a primary care physician, and waiting times for specialty treatment have grown so long that the Canadian Supreme court judged in 2005 that government-monopoly health care violates citizens’ civil rights. Indeed, American and Canadian health care are equivalent in one respect: Patients control very little of the cash flow – only 15 cents on the dollar.
Hawaii passed a law for compulsory health insurance in 1974, but the Aloha State has never claimed success. The State Health Insurance Program of Hawaii “moved the state closer to universal coverage” in 1989. As late as 1993, Hawaii’s efforts at “universal” coverage were described by a scholar as “lodged somewhere in midstream.” If it were only so easy! In 1974, one in 50 Hawaiians was uninsured. Today, after more than three decades of mandatory insurance, that number stands at one in ten. Of course, Hawaii is not immune to national trends, but scholars have concluded that the state’s pay-or-play mandate might have reduced the ranks of the uninsured by 5 to 8 percent at best.
Former governor Mitt Romney of Massachusetts signed legislation for “universal” health insurance in 2006. It has resulted in a terrible trade-off: While uncompensated hospitalization costs have dropped by $250 million, the cost of coverage has gone up by $820 million. And costs are spiraling up so fast that Governor Patrick has formed a blue ribbon commission to change the way hospitals and doctors get paid.
“Universal” health insurance does not have to result in government monopoly. Switzerland, for example, has mandatory private health insurance and lower health costs than the U.S. However, Swiss system has characteristics other than compulsion that likely better explain these positive outcomes:
1. The Swiss tax-code does not punish employees for buying health insurance directly, like the U.S. does, so the Swiss are free to buy health insurance in a robust and competitive individual market. This means the Swiss are able to keep one health insurance policy for as long as they want, rather than switching insurers when they switch jobs. As a result, Swiss insurers have superior incentives and ability to price the risk in their plans than American insurers do.
2. The Swiss government does not order its residents out of private insurance and into a government program when they turn 65, like the American government does. This reinforces the superior incentives discussed above.
3. Swiss insurers have long had the freedom to levy higher deductibles and co-payments than has been practical in the U.S., resulting in lower premiums and leaving more spending under patients’ direct control. American laws and regulations have, until recently, inhibited the availability of such plans to most people. Our traditionally low deductibles and co-payments have led to “over insurance” and significant over-consumption of health care.
The Uninsured Are the Symptom, Not the Disease
I was invited to join the health care reform debate by addressing a set of questions falling under the general theme “Covering the Uninsured.” The problem is that to answer these questions I have to challenge fundamental assumptions underlying them — if one asks the wrong question or misunderstands the nature of a problem, the chances of getting the right answer or solving the problem are slim.
And this is precisely what happens with the three questions I was asked, namely, should all Americans be required to purchase health insurance; what options for coverage should the uninsured and underinsured have; and how do you assess when coverage is affordable. They all assume that the problem is the uninsured or the underinsured. But these are only the “symptom”. The real “disease” is the financial organization of our system.
In all industrialized economies, but ours, individuals do not “purchase” insurance as you “purchase” shoes or cell phone plans. Rather, they contribute to a system whose goal is to eliminate financial barriers to health care. Those systems, to varying degrees, pool risks and are financed by compulsory cooperative contributions.
What does this mean? Well, pooling risk simply means putting everybody into large pools, the bigger the better, and budgeting for people’s medical needs in the same way families budget for their members’ nutritional or educational needs. And why would they do this? They do this because given that the goal of the system is to eliminate financial barriers to care universally and according to medical need, these systems seek to optimize the use of members’ money.
And pooling risk does so in three ways. First, it allows the system to cross-subsidize, which means that at any given moment the healthy or least costly majority pays for the medical care of the less healthy and most costly minority. Cross subsidizing is critical for any insurance system to be sustainable: if a system includes only sick people it will quickly go bankrupt (this, incidentally, is the problem of our American Medicare, because it enrolls only the elderly, who tend to have higher medical costs, and the disabled, whose costs are the greatest. This problem would be resolved by putting all of us into Medicare, and of course getting rid of all the private middle-men that have corrupted it, e.g. “private fee for service Medicare”, “part D”, etc.).
The second thing that pooling risk does is to dramatically reduce administrative overhead, i.e., waste that comes from pushing paper around — to separate people into plans, to market those plans, or to underwrite policies (essentially to deny paying for care). While paper-pushing is the lifeblood of private or liability insurance, because it helps it achieve its ultimate goal, which is not to provide a social service but to make a profit, from the point of view of systems whose goal is to eliminate financial barriers to healthcare paper-pushing is waste.
Third and last, pooling risks gives those systems important market leverage, precisely the leverage Americans lack, which is why we pay the highest prices on the planet for services and goods (e.g. pharmaceuticals) that cost a fraction elsewhere. (And don’t worry: doctors and pharmaceutical companies elsewhere do just fine!).
What about cooperative compulsory financing? Well, this means that participation is not optional and is based on cooperation, or solidarity, if you will. And by making participation compulsory those systems have a guaranteed supply of money. But the cooperative dimension means that nobody is forced to pay what they cannot afford, because that would defeat the very purpose of the system. So contributions are a proportion of income, a mix of taxes or payroll deductions, and align, more or less, with the World Health Organization (WHO)’s requirement pertaining to “financial fairness”. For the WHO, a system that forces you to forego healthcare, or to have to choose between healthcare, rent or food, or that pushes you to bankruptcy (as we do) is decidedly unfair. The rule of thumb is that any system into which people pay over 10% of their income in medical bills (including monthly contributions and out of pocket, extra costs) is “financially unfair”. And mind you, we pay at least that much to finance an extremely dysfunctional system, even this system leaves you on the cold when you need health care (Remember that your taxes foot the bill of all public programs, for the elderly, the disabled, or those who qualify as “poor”, even before you are eligible for any services yourself. In truth, you are “cleaning” the market of “bad customers” and leaving all the “good customers” to the private health insurance sector).
But what about the questions posed by KQED? Well, let me rephrase them.
Should Americans be required to purchase health insurance? As I said, the concept of “purchase” does not fit the systems I just described, which is the one I believe we should have in America, because people elsewhere do not “purchase” health insurance the way we do.
And what “options” should the uninsured and underinsured have? Again, others do not “shop around” for “options”, which implies that you need to second guess if you will need an appendectomy, diabetes care, or one week rather than two days in a given operation. Whatever expenses others have for care that the system has considered “medically necessary” will be paid for out of the common pot. If they want over and above that, they pay for it as you do for that pair of shoes that no reasonable person considers is your “right” to have, or is a “basic human need” (especially if like me, you have more than you will ever be able to wear!).
And last, how do you assess your coverage is affordable? Well, if you consider that unpaid medical bills are our first cause of personal bankruptcy, you know where we stand in that one.
Last, will the Obama plan solve our mess? I wish I could believe so, but I do not. For one, it sticks to the wrong conception about how to finance a health care system, assuming of course that the goal of the system is to eliminate financial barriers to health care universally rather than to create a profitable “illness market” or appease the folks who finance your political campaigns. And any system that sends people “shopping around” for policies while leaving the for-profit motive at the center of the system intact is likely to fail. It has repeatedly, for reasons studied ad-infinitum (yes, health policy is not rocket science!) and we have no reason in the world to believe it will be different this time.
We Can’t Treat Our Way Out of This
Only one-tenth of our population’s health status is influenced by what happens in hospitals and doctors’ offices. In theory, health policy is broad, and encompasses physical, cognitive and emotional well-being. In practice, however, health policy boils down to medical care policy. Case in point, I attended the administration’s western health forum hosted by The California Endowment and facilitated by two governors and the White House health policy czar. The one presenting organization with a primary focus on population health, the American Public Health Association (APHA), was last in the speaker’s cue and rather than the 3-5 minutes accorded other speakers, given only 1 minute after several warnings that time was up.
Unfortunately, medical care sucking up all the air in the room, leaving public health gasping for breath, is the rule, not the exception. The Obama administration could begin to redress this by appointing a specialist in preventive medicine and public health as surgeon general. That’s what we’re trained for, just as neurosurgeons are trained to address lesions of the central nervous system. Perhaps even someone who has experience running things—a little trial by fire under her or his belt.
Second, they could follow the title of their health forums and recognize and make the best use of all health services. Physical education (PE), for example, is a federally-subsidized health service. It’s our last opportunity as a society to inculcate the love of activity, joy of movement and competence at sport or dance to prepare kids for a lifetime of good health until they take their last breath. JFK, to whom Obama is often compared, said that physical fitness is the basis of all other forms of excellence. So we need “No Child Behinds Left” regulations to hold schools accountable for supplying optimal levels of physical activity and physical education K-12, and the resources to do so, not the unfunded mandate that constitutes our current anemic stab at PE.
Third, they could “walk the talk,” starting with some internal housecleaning. Just like smoke-free workplace requirements, all government facilities and beneficiaries of federal largesse should operate under a “fit organization” mandate. First and foremost, a fit organization does not coop people up for hours on end with no physical activity! Lest you say, workers are free to walk during lunch or after work, human nature dictates sedentariness in adulthood and, as noted earlier, we haven’t exactly offered stellar PE programs to habituate people to the alternative. So enjoyable group “recess” breaks need to be seamlessly integrated into daily routine just like meeting refreshments and lunch, organizationally-integrated eating during the day—expected, normative and ritualistic. Add too-good-to-pass-up mass transit subsidies, and parking and employee drop-off locations at least a 10-minute walk from the workspace, allocating nearby spots for the disabled.
Furthermore, we no longer sell cigarettes in VA hospitals, so we should no longer sell nutrient-poor foods in government facilities. We don’t allow tobacco companies to ply their trade in our schools, so why do we allow fast food chains that access, helping to create generations of junk food junkies? Nutrient-rich foods and beverages should be offered widely and cheaply—thanks to government subsidies for fruits and veggies for human consumption, rather than for corn to supply animal feed and high-fructose corn syrup production, ingredients of mega-sodas and dollar menu burgers—relegating the now-expensive and nutrient-poor variety to a corner of the basement.
Like PE in schools, we shouldn’t expect employers to foot the entire bill for these wellness services. Tax incentives should be provided, but only for approaches that make the active choice and healthy food choice the default choice and the sedentary choice or nutrient-poor choice difficult. Otherwise, we as taxpayers will be paying for active, well-nourished people to be a little more active and better nourished. That will not produce a meaningful return on investment, and will be trashed and ultimately ditched.
Hmm…haven’t gotten to medical care yet, have I? Guess that’s because these other measures would improve the health status of Americans and relieve a medical care system at the breaking point. We can’t treat our way out of this. We haven’t the money, time, political will or system capacity. We’re going to have to dam the flood, not just bail the water.
Health ≠ Health Care
Most people who live long and healthy lives in this country do so without much assistance from the U.S. health care system. In fact, a reasonable goal of most Americans is to live a life that allows us to avoid hospitalization, emergency room visits, and even our physician’s office, except for routine screening and preventive services. The best strategy for doing this is to avoid acquiring a chronic disease. The medical care costs of people with chronic diseases account for more than 75% of the nation’s $2 trillion medical care costs. Chronic diseases, (primarily heart disease, stroke, cancer, and diabetes), are the cause of seven of every 10 Americans deaths. The prevalence of chronic disease in a community is a primary driver of the demand for health care services. Much of this is preventable.
While access to a high quality system of affordable health care is an important human right and a necessary strategy for improving health and quality of life and reducing health disparities, health care alone is not sufficient to “produce” health in populations or to drive down the prevalence of chronic disease. We know that health, disease and death are not randomly distributed in communities. Illness concentrates among low-income people residing in certain geographical places. In Alameda County, this phenomenon is particularly stark among low-income African Americans in certain neighborhoods in Oakland, however, Native Americans, Pacific Islanders, Native Hawaiians, Latinos and other immigrant groups of color also suffer a disproportionate rate of disease based on income and geography. The primary manifestation of these health disparities is in much higher rates of chronic disease. A civilized society does not consign whole populations to foreshortened and sicker lives based on skin color and bank account size. The question for us is: Are we a civilized society? If we are, then we must solve the riddle of poor health and its linkage to race and place. The key to this riddle is health equity.
Health inequity is related both to a legacy of overt discriminatory actions on the part of government and the larger society, as well as to present day practices and policies of public and private institutions that continue to perpetuate a system of diminished opportunity for certain populations. Inequities in the economic, social, physical and service environments continue to create and maintain clear patterns of poor health in Alameda County, statewide and nationally. Social inequity causes health inequity.
Deliberate public and private policy helped create the inequitable conditions and outcomes that confront us today. Consequently, deliberate new policy is needed to “unmake” inequitable neighborhood conditions and to decouple health from race and place. Such action might include formal legislative policies such as laws to encourage mixed use housing, universal preschool, or transportation funding. It might include organization-based policies that are not legally required, but designed to improve our collective ability to address health inequities. Different ways of doing business would include new partnerships between health departments working with different city and county agencies, crossing disciplines and sectors. Finally, informal policies would also influence our ability to work together to eliminate health inequities.
With health care reform a major national priority, we have a tremendous opportunity to make strategic investments in primary prevention that will reduce the burden of chronic disease and eliminate health disparities. The current health care reform debate is driven in large part by concerns about ever-growing, unsustainable costs. Immediate cost-containment efforts are necessary, but they alone will not solve the long-term problem— more lasting changes are needed. Chronic disease rates are the major force driving up the costs of health care. Primary prevention is a systematic process that promotes healthy environments and behaviors before the onset of symptoms, thus reducing the likelihood of an illness, condition, or injury occurring. The bulk of those preventive strategies, particularly the community-level strategies, occur outside of the health care system and are strongly influenced by social and economic policies particularly policies shaping land-use, employment, transportation, income, and education. California’s experience with tobacco control is arguably one of the clearest examples of the benefits of primary prevention on health status, mortality and health care costs.
Chronic disease in a population is highly amenable to individual and community-level prevention. Health and rates of chronic disease are influenced by factors such as toxins in the air, water, and soil; access to healthy foods, parks, and recreational facilities; and the walkability and safety of neighborhoods. Primary prevention—with an emphasis on improving the environments where people live, work, play, and go to school—is the prescription for reducing the health care system’s burden and thereby reducing the costs associated with paying to treat preventable conditions.