Health Reform Will Fail
Provocative statement… yes. True…yes. Inevitable…no.
If at the end of the current partisan rhetorical warfare in Washington, some actual legislation emerges this fall, many will rejoice in the creation of a concept of an American system of health care. Hopefully the troika of affordable costs, reasonable access, and high quality will be balanced in a way to satisfy the many perspectives involved in this debate. How this is all paid for remains the essence of the political debate. Employer mandate, individual mandate, tax-funded, all of these payment mechanisms will likely be included in some fashion or another. Whether the ultimate system is single payer, managed competition, consumer-owned cooperatives, or some creative amalgam of all of the above, presumably all Americans will be able to wave a membership card and obtain the right to comprehensive health care. Therein lies the problem! To what will this new card actually entitle me?
In Alameda County, we have long recognized that access to health care is a loaded issue. If we simply increase access to the current system, costs will continue to explode and the system will implode under the weight of hospital and specialty care. So we have been working to develop a system of increased access to primary and preventive care; the front end of the system where most of the population’s medical problem can be identified and managed early before the development of chronic complications. The laissez-faire market-based approach to health system design has proven itself to be disastrous. We have seen a proliferation of boutique profit-making medical and surgical services (e.g. plastic surgery, specialty orthopedics, weight loss, concierge practices, medical marijuana). Simultaneously, there has been a contraction of expensive low profit margin services (e.g. psychiatric, HIV, cancer treatment, alcohol and drug treatment, preventive screening).
Consequently, we have been trying to redesign our system of care to make it more rational by enhancing primary care access, developing chronic care management models, developing new points of system access such as school-based health centers, urgent care, and nurse clinics. However, practically all of the incentives in the system work against these efforts. So primary care and preventive services are under-reimbursed, insurance companies have rules against providing a primary care and a mental health visit on the same day, primary care providers are being steered away from high demand settings, investments in electronic medical record systems and information sharing between institutions is impeded by cost and overly conservative and arcane legal interpretations.
Beyond health care, we recognize that we cannot treat our way out of the obesity, diabetes, and chronic disease tsunami that is already upon us. We have to get smart and aggressive about prevention. We are working in schools to help facilitate more physical activity, improved nutrition, and higher health literacy, we are working to get people out of their SUVs and into walking, biking and running lifestyles, we are working with employers to improve worksite wellness strategies and incentives, and we are working with planning agencies to facilitate smart growth. We also recognize that some people, particularly low-income folks and people of color, have been denied access to basic opportunities due to racism and a whole host of other “isms”. This results in poorer aggregate health and substantially shorter life expectancies. This is inequitable and simply unacceptable. Our strategy to improve equity is squarely focused on building social, political and economic power amongst the populations so that they can more effectively participate in the societal debate over how to allocate scarce and precious social resources such as education, employment, housing and other core health protective resources.
So what happens on that exalted day when the 150,000 uninsured Alameda County residents get a new plastic card entitling them to health care services? A large crash ensues as this rush of demand meets the reality of a limited supply of early access portals to the health care system. Alas, we will flood our emergency rooms and crash our system as the most expensive and least efficient part of the system experiences an overwhelming demand for services. We will see waiting lines, over-flowing ERs, loud pronouncements from naysayers about the folly of government intervention in health care, and a swift political backlash that will take decades to reverse. At that moment, all over the country, health reform will be perceived to have failed.
Is this inevitable? No. But to avoid it, we have to repeat the mantra that “health is not just health care”. We have to make strategic investments in people’s “health”, not just health care. To the extent that we implement a new system of health care, it has to powerfully incentivize preventive and primary care, so much so that every American should be able to identify their primary care “medical home”. To create this we will have to forge new ties between public health systems and primary care systems so that, for instance, clinical care in diabetes, is tied to community and peer-based services in physical activity and nutrition, and cancer prevention efforts are linked to community screening and early detection services. This is not rocket science, yet the extent to which the system creates impediments to these simple strategies is astounding. There has been very little public discussion of these realities in the so-called health-reform dialogue. Responsible policy-makers must embrace this thinking and bring about more public discourse of these issues. If not, health reform will fail.