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.
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2 Responses to “Health Reform Will Fail”
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dr. iton, my website will appear off base to you, since it contends that the addressing of social determinates of health mainly outside the health care system is itself the problem. If I ran the alameda county health department, the cultural taboo against insisting on personal lifestyle change would end, and every health plan would add three sentences ahead of blood pressure, cholesterol, and weight, to assess the three behaviors that are the causes of chronic disease. I would have the 10 community health teams tell people that red meat, white bread, and riding in cars causes serious diseases. I would insist that non-violent offenders not be put in cages, but allowed to join in contributory work instead. I would show that lifelong vigorous exercise reduces the stress of materialism, and health is better than money. I would so upset the status quo, that doctors, health insurers, unions, fast food and meat companies, and school leaders would try to sue me. But how could they sue someone who never went to college, yet is 100% correct? They are the ones who should be sued, starting with selling health plans that are structurally incapable of keeping anyone healthy.
Not to mention bankrupting the country, and causing totally unnecessary suffering and early death from easily preventable chronic disease.
It is a pity that a taboo is ruining peoples’ health. Do I get the job?
(more info at freehealthreform.com)
thanks for your good work! donald wilhelm, III
Mr. Wilhem-
Yes, your website will appear off-base, and not just to him. It will appear off-base to many more.
This is a good thing, since it is off-base. It is all the more the pity, since you do get some things right both there and in your post here: physical inactivity and excessive consumption of red meat or of high-glycemic carbohydrates are major problems.
But were you err is really inexcusable. You err by unconditionally condemning the consumption of red meat. This is a guarantee that you will not be taken seriously, even when you are right.
Red meat is still the best food source for pre-menopausal women to get enough bio-available iron in their diet. Since it is also a good source of protein and B12, it has a rightful place in their diet.
The key is to remember the simple idea far older than most of society’s ills, “moderation in all things”. Even pre-menopausal women do not need very much read meat. And too much really is harmful.
But all this, both your post and your website, is focused on the demand curve. Yes, that curve does need attention, but we have to pay attention to the supply curve, too. We have to be able to provide many health services at a much more reasonable price than we have been doing, we cannot count on a motion of the demand curve to magically make this happen.
To that end, Dr. Iton’s article is great. He doesn’t put it in the same language I just did, but he is calling attention to both. If we continue to fail to address both, health reform will fail in very much the manner he predicts.