Yes, I Do Have a Nerve
Yes, I do have a nerve, as Mr. Wright charges, to challenge the principle behind Medicare, which he calls a “generational compact.” (I’m going to have to dig out my old Newspeak dictionary to hold my own in this discussion. Professor Chaufan refers to the principle of “cooperative compulsion,” which sounds ominous.) I’m pleased that Mr. Wright does not think it’s a “bailout” for him to finance his parents’ health care and hopes his children will do the same for him.
Well, I’m in the same boat. So, I’ll be happy to enter into a “compact” with Mr. Wright (and everybody else): if he’ll ask the government to return the share of my paycheck that it has taken for Medicare, which his parents use, then I’ll ask the government to return the share of Mr. Wright’s paycheck that it has taken for Medicare, which my parents use. That’s cutting out the middleman!
Mr. Wright acknowledges that single-payer (a.k.a. government monopoly) health care is his preference, but gracefully acknowledges that there are as many different “systems” as there are countries. His essay communicates a core value that the “system” be financed by progressive income tax. Well, more of it is financed by a progressive income tax than most of us appreciate.
In round numbers, national health care spending in the U.S. will run about $2.5 trillion in 2009, of which $503 billion will be Medicare and $386 billion will be Medicaid. Medicaid, accounting for 15 percent of national health spending, is financed by general state and federal government revenues, which is mostly from progressive income taxes. Almost every senior Medicare beneficiary believes (incorrectly) that he has paid for Medicare through payroll taxes deducted during his working years, and continues to do so via premiums deducted from his Social Security check. In fact, while payroll taxes and premium revenues accounted for 75 percent of Medicare’s income in 1970, they only accounted for 55 percent in 2007.
If a little more than half of Medicare’s spending and almost all of Medicaid’s spending is financed by progressive income tax already, then that means that more than one quarter of health spending is covered just the way Mr. Wright likes it.
And the trend is his friend: The share will likely grow as the Medicare Part A (Hospital Insurance) “trust fund” is exhausted by 2017. Last year, for the first time, Medicare spent more on Part A hospitalization benefits than it collected in payroll taxes, and the 2017 bankruptcy date, reported this year by the Medicare “Trustees,” is two years earlier than predicted in last year’s report. (The terms “trust fund” and “trustees” are ridiculous, because Medicare does not operate a trust fund: The surplus payroll-tax revenues for each year up to 2007 were immediately transferred to other operating departments of the U.S. government.) The government is going to have to look somewhere to fill this gaping hole and “taxing the rich” is more satisfactory than actually fixing the problem.
On the other hand, the taxation of privately purchased health insurance is grotesquely regressive and blatantly unfair. Because the government exempts employer-sponsored health benefits from taxable income, they are far more attractive to higher-income households. An employer-based health benefit of $10,000 is worth $12,500 of pre-tax monetary income to a household with a marginal income-tax rate of 25 percent, but is worth $15,000 of pre-tax monetary income for a household with a marginal income-tax rate of 50 percent. Unsurprisingly, higher earning workers prefer more of their compensation in health benefits, despite the fact that much of the health care we use is ineffective.
Furthermore, one of the primary causes of the lack of health insurance is unemployment. I have estimated that perhaps two million of the uninsured are simply undergoing a waiting period for coverage at their new jobs. Changing the tax code to give workers the same tax-benefit as their employers do, for the purchase of health insurance, would reduce the number of uninsured and improve the fairness of the tax-burden.
Don’t Forget Benefits When Looking at Costs
Debates on health reform can get ideological and philosophical quickly.
But the current crisis with the state budget brings the issue home, as the governor is now proposing to possibly cut coverage for nearly two million low-income children, parents, seniors and people with disabilities. These Californians can’t afford health coverage otherwise and, as a result, will live sicker, die younger and be one emergency away from financial ruin – just like the currently uninsured. Private coverage isn’t faring any better – estimates are that more than half of one million Californians have already lost coverage in the last 18 months of the recession.
When health reformers say the status quo is not an option, it’s not a slogan. The status quo is quickly deteriorating and the cost of doing nothing impacts real people.
We all have preferred solutions to the health crisis, and so while I would agree with Claudia Chaufan for single-payer as my preference, I disagree that anything else is not worthy of consideration. After all, there literally are as many types of universal health coverage plans as there are countries in Europe.
And even passage of a single-payer system would not end the ongoing public debate about the appropriate level and structure of taxes versus the level and type of services they would pay for. But it’s a good debate to have.
Single-payer would seek to replace what we currently pay in premiums and cost-sharing with a progressive tax system. Other reforms would seek, through cost-savings or subsidies, to make health coverage cost no more than a percentage of a person’s income.
That’s an important principle – to move to a health system where we pay based on what we can afford, rather than the current system where we largely pay based on how sick we are. Individual insurance costs more if you are older and sicker, and cost-sharing in any plan (through deductibles and co-pays) is by definition more expensive the more you need and use it.
We do have some safety net programs, but because they are limited, they have limited support and perhaps don’t get the financial support they need, especially in bad financial times like these, as the current budget crisis shows. Medicare gets broader support because it is universal for those over 65. John R. Graham has the nerve to call the generational compact of Medicare a “bailout.” I’m not “bailing out” my parents and grandparents by helping finance their health care; it’s in my interest for them to have health coverage in their retirement years, and I hope and believe my child will think the same when I am retired.
Finally, John R. Graham wonders why, in the Massachusetts plan, it is a good trade-off to spend $820 million to get savings of $250 million. The answer is the 400,000 people who have public health insurance coverage that didn’t have it and couldn’t afford it before. Whatever you think about the plan, it lowered the state’s uninsured rate from 10% to nearly 2%. I have my own critiques of the Massachusetts plan, but it seems disingenuous to talk about cost without mentioning the benefit to hundreds of thousands of folks, especially when talking about “cost and benefit” in the very same sentence. And it seems that those in Massachusetts are paying for the security – let’s call it insurance – that if they fall upon hard times, find themselves between jobs, etc., they will have access to affordable care, as well.
It’s a neat trick for John R. Graham to argue against taxes and then point to shortfalls in Medicare and Medicaid. If you underfund a health plan, it will be underfunded. That doesn’t change the fact that Medicare and Medicaid provide care to poorer, older and sicker populations by definition, and do so at a cheaper price than the private insurance companies.
No health coverage is going to be free. But the question is how can we provide health coverage more efficiently, effectively and affordable for all. And I would rather have the debate – deciding what we are willing to pay for the health care we need – in public in the context of a democracy, than have those decisions about premiums and costs solely made in private in the corporate boardrooms of insurers.
Bridging the Work of Prevention and Care
Throughout this series, I have challenged us to expand our definition of “health policy.” As Dr. Iton’s post eloquently argued, our nation’s health disparities have more to do with inadequate labor and education policies than “health care” and “access” issues. A key step to addressing health equity by developing more integrated policies is to break down traditional silos and start creating multidisciplinary efforts.
I was therefore encouraged by the mention of multidisciplinary care teams in the recent position paper by the Senate Finance Committee, “Expanding Health Care Coverage: Proposals to Provide Affordable Coverage to All Americans.” [PDF] The product of the Committee’s round table discussions on health care reform, this paper focuses on ways to expand coverage and improve the delivery of care.
While much of the document’s discussion of prevention is vague and underdeveloped, the inclusion of “Prevention and Wellness Innovative Grants” gives us our first glimpse that public health voices are being heard in Washington. Under this policy option, states would receive funding to promote and reward programs that establish integrated models for health maintenance, reduce chronic disease rates and facilitate the coordination between health and human service systems.
For these programs to truly move beyond our limited focus on treatment, they must have the flexibility to look past traditional allies in the health sector and develop partnerships with stakeholders across the social service sector. As Dr. Yancey writes in a recent post, “we must align our public health objectives with those of a variety of organizations and agencies across many sectors and content areas.”
Key models of this work have already emerged in California. For example, St. John’s Well Child and Family Center has complemented its clinical care for asthma patients by forging new alliances with affordable housing developers and using community promotoras to reduce environmental triggers in South Los Angeles.
As the pace of the national debate quickens, we must make sure that primary prevention policies addressing health equity are included. Go here for copies of the policy position papers. Public comments on coverage issues are due by May 22 and comments on financing options on May 26. It is anticipated that the Finance Committee will quickly follow with bill language in the first week of June.
Public comments on the Senate Finance Committee’s papers should be directed to Health_Reform@finance-dem.senate.gov.
Prevention – Got Change?
There’s considerable agreement and common ground among those of us involved in combating health disparities, broadly defined. That agreement includes the modest portion of health status that can be addressed by appropriate medical care. But that’s about as far as most go—identifying what needs to be done outside of the clinical encounter, but stopping short of how to get that done. Unfortunately, that’s a chronic problem with disparities research and practice. The overwhelming majority of the resources are dedicated to observational studies further defining the problem and its parameters, populations affected, interactions between such sociodemographic factors as race/ethnicity, gender, region of residence, and income. Rather than intervention studies testing solutions, or even qualitative investigations to guide the development of innovative and pragmatic solutions to test.
An important step toward getting health care reform done this time is the specificity of the approaches to accomplish it and engaging stakeholders from various perspectives in grappling with the nitty gritty details to arrive at something we can all live with. So let’s begin with identifying some levers to spur the physical, socio-cultural, organizational and economic environmental changes necessary to reshape the societal landscape to promote health and well-being.
Let’s start with the existing infrastructure. It’s going to be difficult enough to loose the resources to provide universal health care coverage. The only way to create sustainable change is to build the necessary changes into the systems we have. Second, we must align our public health objectives with those of a variety of organizations and agencies across many sectors and content areas. Leaders seek to operate in the best interests of their own organizations, and are strongly incentivized to do so, whether in the public sector by elected and appointed officials, or in the private sector by owners and shareholders.
Strengthening linkages between public health agencies, community-based organizations and academic institutions is particularly necessary in that each entity embodies complementary and synergistic roles and missions in the practice of public health. Public health agencies have consistent funding streams (however inadequate) and mandates for improving the health of entire geographically-defined populations. Community-based organizations exist to represent the preferences and respond to the needs of their targeted populations; they may mediate between the needs of individuals in a specific locale and institutional bureaucracies charged with addressing those needs at a societal level to achieve certain outcomes. Colleges and universities are repositories of scientific expertise, are measured by research grant and publication productivity, and have a central focus on educational activities. With the increasing attention to, resources available for, and validation of “academic public health practice” and “community-based participatory research,” the applied research and training opportunities presented by collaborative community health improvement projects could fuel further investment by universities, federal agencies and foundations.
To facilitate practice-based solutions, it may also be important simply to do a better job of capturing intervention effects. Better instruments are being developed to assess organizational support, social network interactions and economic influences. However, independent evaluation efforts can be quite costly and challenging. A part of the solution may rest in government investment in expanded surveillance to provide risk behavior and disease prevalence estimates for smaller geographic areas (e.g., ZIP codes or census tracts). External sources of evaluation data, capturing secular trends and presumably intervention effects, would decrease the burden of research participation on community-based organizations and local health departments, allowing them to focus on the service missions that motivate their involvement.
For example, if our research demonstrates the beneficial influences of healthy eating and physical activity on student concentration and attentiveness, cognitive processing, discipline, and academic performance, school systems are much more likely to “carry our water.” However, if we focus solely on health, they may agree that it’s important, but how much can they add to their already crowded plates? How many unfunded mandates are already in the queue? Here in California, we can monitor the success of policy and programmatic interventions through existing data collected by the state education department, foundations, universities and the feds, e.g., the FitnessGRAM, the California Health Interview Survey and the California Healthy Kids Survey.
If a central premise of improving health and addressing health disparities is building upon existing community infrastructure, organizational settings will be integral to service delivery. These settings (e.g., government agencies, clinics, social services agencies, civic associations, professional networks, religious institutions, sports organizations, youth groups, schools, child care centers and pre-schools) are key starting points in moving the needle on health in underserved communities. Let the dialogue begin!
Today’s “Public Options” Are Already Bankrupt
Mr. Wulsin reports the Congressional Budget Office’s conclusion that private insurers pay providers 20 percent to 30 percent above their costs; Medicare’s payments lay somewhere above or below the line; and Medicaid pays about 20 percent below costs.
We call this the cost-shift, which increases private health insurance premiums by about 15 percent, according to a December 2008 study by Milliman, Inc., a firm of actuarial consultants.
Mr. Wulsin is tempted by a new “public option” designed after Medicare, because stingy Medi-Cal (California’s Medicaid program) would face some sort of competitive pressure: people who would have enrolled in Medi-Cal would go to the federal public plan instead, relieving pressure on providers’ revenue and somewhat averting the crisis.
Fortunately, he rejects this temptation for operational reasons: local governments have been more able to tailor effective health programs than Medicare, which usually relies on a fee-for-service model with prices fixed by bureaucrats in Baltimore.
But there is another reason that a “public option” for all would not succeed in covering the uninsured effectively: we just can’t pay for it. Certainly, Californians’ defeat of tax hikes this week means that fewer providers (or managed care plans) are going to want to contract with Medi-Cal, and its beneficiaries will jump at the chance to bail into a federal “public option” bolted onto Medicare.
But the taxpayers simply could not cope with it. Medicare is perfect for the political class, because they rely on seniors’ votes. So the political class has designed Medicare to maximize seniors’ support. Think about it: you start paying into the Part A (hospital) fund as soon as you start working, without any enforceable guarantee describing what it will pay for once you turn 65. Once you retire, you pay a premium for Part B (physicians’ services), which covers only one quarter of the total cost of Part B. Originally, it paid for half the costs, which had been whittled down to a quarter by 1980. Don’t get me started on the Medicare Part D drug benefit, for which premiums cover only 10 percent of the costs.
Who pays the rest? The working-age taxpayer, of course, whose income taxes bail out Medicare every year. Incredibly, despite collecting premiums from beneficiaries for almost half a century before they receive services, massive subsidies from working-age taxpayers, and barely covering providers’ costs, Medicare still has an unfunded liability of almost $90 trillion looking forward to infinity. It is unreal that people are still talking about a “public option” after the latest Medicare Trustees’ report, released earlier this month.
The only reason Medicare “works” is because of a continuous bailout from non-beneficiaries (including generations yet unborn) to beneficiaries. Its ability to execute this fiscal raid shrinks dramatically once the state enlists every citizen as a potential “beneficiary.” The result is denial of care. When I lived in Canada, the “crisis” was a lack of high-tech diagnostic machines. Now it’s much more basic: about 15 percent of the population has no access to a primary-care doctor, according to the College of Family Physicians of Canada.
So, I think it’s great that Mr. Wulsin advocates local control of health-care dollars. But there’s no need to stop at the county or municipal line. Continue to the property line and give families and individuals control of health care dollars.
What Do We Owe Each Other?
Americans have a lot of trouble directly addressing what we owe one another with respect to health care. Do we owe each other free access to any health care services in any setting at any time, as a fundamental human right — as several previous posts seem to suggest? Do we owe each other nothing, instead treating health care as a private consumer responsibility that competes for a share of household budgets with groceries, car payments, and cell phone bills?
A couple of years ago, the Center for Healthcare Decisions — under its “Just Coverage” project — asked Californians whether health coverage should be like:
• the fire department (everyone receives the same level of protection, regardless of income);
• education (a basic level is guaranteed for everyone, but those who can pay more may do so); or
• housing (everyone has the responsibility to meet his or her own needs).
The majority of responders found education the best analogy; they believed that Americans owe each other a “basic” level of protection, but are open to individuals paying for more services on their own. The ongoing challenge we all share is reaching a shared definition of “basic,” to help decide just what constitutes that fundamental, shared obligation.
I recently spoke on health reform to a group of high school government students, as part of a presentation on interest group politics. One student, who seemed to be a libertarian outlier in this Bay Area group , asked what was wrong with having everyone just pay their own way for health care, regardless of their health status or financial situation. I answered, basically, that that wasn’t the kind of world I wanted to live in. As the health reform debate unfolds, the question before us is: what kind of a world do we want to live in – and what are we willing to give up in order to get there?
The Elephant in the Room
Why is it that my students get it, attendees to my talks get it, readers of KQED get it, yet New York Times reporter David Leonhardt doesn’t get it?
Because, soon after my first posting was published on this website, explaining in very simple terms how every other industrialized economy in the world manages to guarantee at least a basic, often very generous amount of health care to all their people according to medical need and not ability to pay – at no more than half of what Americans spend collectively – here comes Leonhardt whining that without “political pain” on “ourselves,” we cannot achieve universal health care.
Leonhardt points out, correctly, that we cannot have reform without controlling costs, because otherwise we won’t be able to pay for everybody’s health care. However, he incorrectly concludes that we can only control costs (and get the $120 billion per year he estimates we need) by taxing employer-provided benefits (which he claims currently force government to forgo $250 billion in taxes). So, with the menu of imaginative options legislators are considering to reform our health care system, you might be able to keep the employer-provided health care you presumably like, as the President promised, but it will be taxed, and thus will be a lot more expensive. Ouch! Painful, no?
Honestly, I am at a loss. Didn’t Leonhardt read my posting? Maybe he consulted the wrong folks, like Jonathan Gruber, an M.I.T. economist (yes, M.I.T.!) who, as Leonhardt quotes, cannot imagine “where else you get enough money” to pay for universal health care. (How about asking bankers how they got the bailout money? Just kidding!). Can these folks seriously not imagine organizing a national health insurance program without the waste that comes from putting for-profit health insurance at the center of the game?
I am confused. I assumed that the New York Times, given its prestige and its huge role in shaping public opinion, hired reporters with good arithmetic, a basic grasp of logic and a reasonable amount of common sense – am I wrong?
Okay, whichever the case may be, let me give Leonhardt, Gruber and New York Times editors some ideas. And they don’t have to pay me. I gladly give them for free, because I did not invent them. And the “inventor” of social health insurance, whose principles I lay out in my first and second postings, is dead anyway, so he won’t complain. It was Otto Von Bismarck, First Chancellor of the German Empire, who sponsored the first social health insurance system in the world. Not, mind you, because he cared about equity, as my readers or I might, but rather to prevent the rise of socialism, which was gaining the upper hand with German workers, tired as they were of producing wealth yet receiving always the short end of the stick. And having seen the 1848 revolutions and the Paris Commune in 1870, Bismarck realized that workers meant business.
My apologies for following that tangent – it is so frustrating! David, how can you control costs in health care, a wholesome and necessary pursuit that I wholeheartedly share, without shortchanging workers? Let me repeat, especially for you (because readers of this blog are very sharp already) what all other industrialized economies do, and suggest that you consult the European Observatory or Health Canada websites.
Other countries more or less do at least one thing: they pool risks. That is, they put everybody in large plans, or better still, one single pool or plan. Yes, counterintuitive, David! One size DOES fit all, because all you want in a health care plan is for it to pay for all the medically necessary care you need, when you need it, from the doctor you like, and that it not break your financial back!
In our case, experts have estimated that pooling risk would allow us to cut around $400 billion in administrative overhead — and to think you were worried about $250 billion! And pooling risk would also allow us to purchase in bulk. Because, David, as prestigious economists figured out a long time ago, “it is the price, stupid!” Yep. They even wrote a paper with that title, showing that we use less health care than other countries, yet spend more, and concluded, applying simple logic and basic arithmetic, that if you pay more for the same thing and get less of that thing, you must be paying higher prices.
Now, they did not talk about cross-subsidizing, another critical feature of large pools, as I have. But, in fact, even private insurers – who are not terribly good at providing health care, yet are good at figuring out how to save a buck (by not paying for your health care) – could figure this one out. Alissa Fox, vice president of Blue Cross and Blue Shield Association, was quoted in the New York Times as saying that “Insurance works best when everybody is in the pool […] you need healthy people in the insurance pool to help pay for sicker individuals.”
So, David, there you go: just put everybody in one pool and you will control costs: you will cut administrative waste, get great prices and cross subsidize. And you will have all the money you need to pay for all the medically necessary care you need for the entire population! Because, in case you did not know, David, we are already paying for universal health care yet not getting it [pdf] (again, experts figured this one out long ago), because we pay more in taxes, even before we get any services, than other countries pay to cover 100% of their population – 10% of our income on average, David. As Joel Harrison wrote, “we pay more and get less.” And this even before you paid for your premiums, let alone your out-of-pocket costs!
At the federal level, single payer is called HR676, and if you are reading my posting (I hope you are, David), just click here and a 5-minute video will explain it.
You just have to think outside the box, David. And don’t worry about politicians. Sooner or later, they will realize that elephants in rooms cannot be ignored forever.
Thoughts on Affordability and the Public Plan Option
Affordability must encompass the short and long term, and must include both premiums and anticipated out-of-pocket spending. While I favor a public plan option, I favor a very different model than may be considered in Congress, which has been discussing an option for any individual under the age of 65 to opt for Medicare. I think we have some excellent local public health plans in California, such as San Francisco Health Plan and Health Plan of San Mateo, which I think represent a better model for extending coverage to the uninsured, and they are far more affordable for those who select them.
The proponents of the public plan are, for the most part, putting forward a Medicare model. Medicare has the following attractions: a rate structure well above Medi-Cal and uninsured reimbursements, low administrative costs and a broad, open panel of doctors and hospitals who accept Medicare patients. Medicare has sizeable deductibles, co-pays and coverage limits, which forces many seniors to buy supplemental private insurance coverage. Medicare also provides little coverage of long term care, like nursing home stays. To qualify for long term care, seniors must be poor enough to qualify for Medi-Cal (Medicaid). When it comes to prescription drugs, Medicare prescription drug coverage includes the infamous doughnut hole, which leaves seniors with thousands of dollars of non-reimbursed drug costs.
For most hospitals and clinics seeing a large volume of California’s seven million uninsured, Medicare levels of reimbursement would be a large payment upgrade. This would put pressure on Medi-Cal, which currently covers more than 6.5 million Californians, to follow suit. This would represent a very large increase in revenues for those providers caring for 13.5 million Californians – about one third of all patients.
According to recent Congressional Budget Office analyses, right now, commercial insurers may be paying providers about 20%, sometimes 30%, above their costs. Medicare may be paying above or below cost, depending on whether you are a high or low cost provider. Medi-Cal pays well below cost, let’s say 20% below cost or maybe more (this does not apply to some community clinics and public hospitals that get actual cost-based reimbursement in California). Payments for California’s uninsured are highly variable – from nothing (as the costs of care are charity care or a bad debt write-off) to three times hospital costs (for a few people who pay hospital “charges”), from a percentage of Medi-Cal or Medicare rates in some counties, to the actual cost of hospital and clinic services in others.
In economic theory, commercial rates should come down substantially when we cover the uninsured and if we increase Medi-Cal rates substantially. But in the Alice in Wonderland world of health care, they most likely will not; what goes up does not come down unless some strong countervailing pressures are applied. Thus, it is argued that giving any individuals who prefer the Medicare option the right to enroll would serve as the countervailing pressure on private insurance prices and premiums so that the private ratepayer gets the break from increasing Medi-Cal rates, and providers are reimbursed for their care to the uninsured. This too is a good but untested and unproven theory. The objections of commercial plans to the Medicare model seem to me to miss the point; they should be able to be far more nimble, cost effective and deliver superior quality services at lower costs than Medicare, which has far fewer controls on unnecessary utilization and is hampered by an outdated payment and benefits structure that needs repair.
While Medicare has advantages, I would suggest that Medicare is not the best reimbursement and delivery model for several reasons. First, it is fee-for-service, yet half of all privately insured Californians are in HMOs that are less costly than fee for service by up to 15%. Second, it is an open panel model, while most Californians are in closed panel models; closed panels can better control costs and improve quality. Third, it is not integrated at all; it is the obverse of the successful Kaiser Permanente and Group Health Plan models, which I think should be the model for the public plan. Fourth, it is slow moving; it took forty years to add prescription drugs, while Medi-Cal (Medicaid) and private insurers added this and other important benefits far more quickly. Lastly, it does not create the important reforms of delivery structures to improve quality of care, and is not particularly well suited to do so. This is not to denigrate the good work in developing Medicare’s DRG (Diagnosis Related Grouping) reimbursement for hospitals and RBRVS (Resource Based Relative Value System) for doctors, but we simply need far faster and nimbler evolution and stronger incentives for greater efficiency and quality.
I think the better model of public plan is home grown: California’s local County Organized Health Systems and Local Initiatives. They connect more readily to the uninsured than do the commercial plans, as their delivery structures are in the communities where the uninsured reside. They can and do create reforms in the delivery system, which is what we urgently need to control costs and improve quality. They have the linguistic and cultural connections and capacities to care for the diverse populations of our state. They compete effectively head-to-head with the private sector plans in the Healthy Families and Medi-Cal markets. They have low administrative and other non-benefit costs. They have affordable co-pays for lower income Californians, unlike much of commercial insurance and Medicare. They include the safety net clinics and hospitals, and the doctors from low-income neighborhoods who typically have a hard time finding a welcome mat from the large commercial insurers. They innovate, creating new programs for uninsured home care workers, cab drivers, children and low wage uninsured workers, just as Santa Clara, San Francisco and others have done. Health care is local, and these plans are far more able to adjust to local conditions than a large multi-state insurer or Medicare can.
They do need to consolidate more broadly, forming regional plans, rather than plans constricted to county boundaries as we have now – eventually evolving into one for the Central Valley, for example, one for the Bay Area, one for the rural North, and one for Orange and San Diego. There are several plans that are already regional in scope serving the Inland Empire, Solano-Napa-Sonoma and Central Coast regions. Meanwhile, the Los Angeles Care Health Plan will need to evolve from the umbrella plan that now exists to a fully integrated plan, as best exemplified by Kaiser and the innovative and highly competitive local health plans in San Francisco, Contra Costa, Santa Clara and San Mateo.
Our Accent is on the Wrong Syl-ˈla-ble
The current health care reform debate is entering high gear and, of course, the primary focus is on covering everyone, controlling costs, maintaining “choice” and incentivizing innovation. This is a long overdue discussion in a civilized society; however, the ridiculously narrow parameters of this discussion are astoundingly ignorant of the underlying realities. While health care reform is necessary, it is not sufficient to improve the overall health of Americans or to reduce shocking health disparities that thoroughly characterize the U.S. health status quo. Health care is a repair shop where we take our bodies when warning lights are flashing. But what makes our bodies break down in the first place, and why is it that some populations seem to break down so much more often than others?
An African-American child born today in West Oakland can expect to die 15 years earlier than a White child born in the Oakland hills. Why is this? It is because over one’s life, health depends much more on education, employment, access to recreation, healthy food and clean air, than it does on access to doctors, pills and MRIs. So having a great repair shop isn’t as important as having smooth roads that reduce the wear and tear on our bodies. How do we smooth those roads? Well, we have to make sure that our health system is heavily invested in prevention so that we avoid the predictable problems and only use the repair shop for regular maintenance, or if we have a catastrophic accident.
How can the current health care reform policy debate incorporate this basic wisdom? First, start by making deep and strategic investments in prevention. Fund public health to ensure that all children are immunized and that expecting mothers, particularly in low income families, receive pre and post natal care and support. Create strong incentives for proven health screening including colonoscopy, mammograms, Pap smears, diabetic eye and foot exams, and community-based peer and self-management efforts in nutrition and exercise. Invest heavily in community health workers, promotoras, health navigators, and community-based primary care, such as community health centers. If we want to improve cultural competency and health care access, we should at least be heavily subsidizing primary care, instead of pouring money down the black hole of emergency rooms and ICUs.
In concert with health care reform, reform other critical policies that have huge health impacts:
1. Invest deeply in early childhood education so that all of our children have access to high quality preschool and can enter kindergarten healthy and ready to learn.
2. Reduce the high school drop out rate to change the life trajectory of so many low income kids who, without a decent education, will lack the critical thinking skills so necessary to compete in the 21st century economy. We know that less education equates to a greater likelihood of shorter and sicker life.
3. Employ low income people. The best prescription for overall good health is a good job with a meaningful career ladder. Chronic unemployment kills.
4. Pay people a living wage. It is unconscionable to allow full-time workers to earn less than the federal poverty level. Work should lift you out of poverty, not keep you mired in it.
Universal access to a system of high quality and affordable health care is a basic human right, but it is not sufficient to improve America’s health status and eliminate health disparities. Our policy makers should take advantage of the wisdom garnered from health studies all around the world and recognize that health does not equal health care.
Invest in Universal Health, Not Just Health Care
In spite of all of the high-minded talk, much of which I agree with, to make a real difference in health outcomes, cost, and system performance, we need a health system that has one goal in mind: cover the health of a person over their entire life. Anything less will perpetuate all of the inequities, inefficiencies and poor coordination that have been mentioned on this blog when it comes to coverage, access, quality, cost, etc. We had a lot of talk by some about universal coverage. Universal coverage alone is not sufficient to reduce the absurd 35-year difference in life expectancy across different classes of Americans. Universal coverage alone is also not likely to greatly improve the United States’ ranking of 46th in life expectancy and 42nd in infant mortality among 192 nations. The goal must be optimal health for all of us, not just the wealthy, not just the poor, but for all of us.
Over the last 40 years, new knowledge has transformed our understanding of what determines health. We know much more about how particular diseases evolve over decades and how socioeconomic and environmental influences align to channel long-term health outcomes. But little of our conversation about what is needed to reform the health care system, and the ways in which we judge how well the system will do, incorporates these paradigmatic shifts in our knowledge about what triggers poor health and determines good health. Our policies need to encourage innovation in the organization, financing, and delivery of health services that exploit this new knowledge to catalyze genuine improvements in our health.
What our country really needs is variation on what UCLA’s Blue Sky Health calls “Universal Coverage PLUS;” we need Universal Health. We need health systems reform and universal coverage that also addresses the social, behavioral and environmental determinants of health [pdf]. We need to bring health and health promotion from the fringe to the core of the health system. Such an approach would restructure the health system to promote our health over the long periods in our lives during which health problems develop. We need to invert our after-the-fact health system on its head, so that a new and more robust form of health care can emerge. Moreover, health care funding needs to expand beyond paying for individual care, to making strategic investments that promote the health of specific populations and communities.
In undertaking this approach we should start with our children. This county must make a stronger, more significant down payment on its future health than it currently does. Using health reform and universal coverage for all of us as the foundation, we should make additional reforms that transform the ways in which we prevent disease and promote optimal health among children and adolescents. This would serve as an important national test run for the type of new health system that would have health and health promotion built into its “genetic code.”