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.

Let’s take physical activity, my favorite example of non-pharmacological, non-surgical, non-psychotherapeutic “medicine.” Physical activity is one of the most potent and grossly underutilized tools in our prevention arsenal. The data supporting the effectiveness of modest “doses” of exercise in preventing, managing and, on occasion, even curing a host of chronic disease maladies is overwhelming. Participation in doses as modest as 50-60 minutes of moderate-to-vigorous intensity physical activity per week confers some health benefits; engaging in at least 150 weekly minutes is associated with a full spectrum of protection across most health and wellness domains, and augmentation of disease management and rehabilitation—from A to Z, academic achievement, Alzheimer’s disease and depression, to obesity, stroke and other vascular diseases. Yet, a recent study of data from the National Health and Nutrition Examination Survey (NHANES) gathered from objective monitoring of activity levels revealed that Americans participate in an average of only 6-10 minutes of at least moderate intensity physical activity each day. A study of ours a few years ago [PDF] found that more than 40% of Los Angeles County’s more than 10 million residents is completely sedentary, engaging in fewer than 10 minutes per week of continuous activity.

An early and concerted emphasis on physical activity should assume primacy in any comprehensive effort to promote health and well-being, prevent chronic disease and contain medical care costs. Preventing weight gain, much less achieving healthy weight status is highly unlikely to be sustainable at the low levels of physical activity in which most Americans engage. Yet we constantly look elsewhere for solutions, rather than looking for delivery vehicles for this “miracle drug.” So here are three focused strategies for achieving sufficient increases in physical activity across the entire population to realize meaningful health and wellness benefits. This will not only ease the strain on the medical care system but also on the overall economy by increasing productivity, decreasing injury and workers’ compensation liability, and improving student and employee morale and retention:

1) Adopt “opt-out” or “push” organizational practices and policies that make the physically active choice the default option or path of least resistance, and the sedentary choice difficult, in schools and workplaces, especially government-run and government-regulated agencies, e.g., exercise breaks at a certain time of day or reserving parking within a 5-minute walk of the workspace for people with disabilities. (See this NPR story for more.) This includes setting day care, pre-school and after-school standards for minimum amounts of physical activity per hour spent in child care. Legislators and other policymakers have wide spheres of influence and this is a “mirror” strategy—rather than instructing others, what can you do within your own decisional latitude? Incentives, e.g., tax rebates, for workplace wellness programs not built on these opt-out strategies will not produce a sustainable return on investment. That’s because the people most likely to take advantage of on-site fitness facilities or programs are healthier and more active than most employees—and willing to spend their own discretionary time and income on active pursuits. Poor structuring of workplace wellness tax breaks will merely shift costs now borne by these individuals to employers and taxpayers.

2) Improve the quality of physical education (PE) by investing resources to increase the number of PE teachers, training of all elementary school teachers in PE, activity-focused PE implementation support materials and equipment), even before much-needed efforts to increase PE duration. We conducted a statewide assessment of PE and physical activity in California public schools [PDF] a few years ago, and found that kids in low-resource schools typically spend only 4-6 minutes being moderately-to-vigorously active (walking, running or jumping) during a 30-minute PE class. More PE time without quality improvement translates only into more time spent sitting or standing around.

3) Impose an excise tax on sedentary behavior-promoting goods and services, e.g., movie tickets, inactive video game consoles and software, private automobiles and cable TV packages. Like tobacco excise taxes, not only would this provide a funding stream for ramping up and scaling up public health coordination of physical activity promotion, but price elasticity would also decrease consumption among adolescents. The revenues might also permit the redress of the inequities in park space in low income communities and communities of color, so kids have someplace to bounce a real ball!

Out-of-the-box thinking? Maybe once we’re strong enough to punch our way out!

What about Dr. Chaufan’s concern that serious consideration of a single-payer approach has been missing in the national health reform debate, and her implication that enacting a single-payer plan would solve the cost conundrum? The Congressional Budget Office may not have estimated the cost of a single-payer approach, but the California Legislative Analyst’s Office (LAO) did just that in 2008, in the context of pending California legislation (SB 840, Kuehl). The LAO concluded that the proposed single-payer plan would require new payroll taxes of about 8 percent paid by employers and 8 percent paid by workers. That totaled 16 percent – not coincidentally, the share of the total economy that goes to health care today. A single-payer approach would cause health spending to flow in radically different ways, but to change the total amount we spend would require additional steps.

In my original post, I laid out a few ways to fundamentally alter how much we pay for health services. None of these is quick or easy. We can change the way care is provided or how we pay for it. We can invest in prevention and health promotion so that less care is needed. We can work to eliminate the use of ineffective care while encouraging cost-effective approaches.

To make progress with any of these approaches will require greater transparency and accountability within the health care delivery system and among those who pay for care. It will leave some of us with less in order to provide others with more.

David Brooks of The New York Times wrote this week that “We’ve built an entire health care system (maybe an entire government) on the illusion of something for nothing. Instead of tackling that basic logic, we’ve got a reform process that is trying to evade it.” The risks and rewards inherent in the political process tend to perpetuate that illusion; human nature inclines most of us to accept it. Given the importance of the task, though, I hold out hope that policy makers and citizens will tackle the tough decisions needed to move the country toward more affordable and appropriate care for all.

Dr. Iton is Canadian, like myself. When invited to comment on so-called “universal” health care in Canada, he stressed the sense of “solidarity” that he believes Canadians feel about everybody belonging to the same health plan, run by government. Well, to the victor, the spoils, I guess. Because the government won the fight for Canadian health care, its advocates get to write the history. However, back in 1962, when the province of Saskatchewan introduced its government-run, “universal” plan, the doctors went on strike. They caved in when the government relented on letting them practice outside the government plan. Later, when private competition frustrated government’s ability to control medicine, Ontario’s doctors went on strike in 1986, as a result of a new law preventing “balance billing” (even if patients voluntarily chose to pay the difference between government’s fees and what a doctor wanted).

For both ethical and financial reasons, the doctors’ bid for autonomy from government failed. It took until 2005 for the Canadian Supreme Court to determine that government-monopoly health care violates Canadians’ civil rights.

But if you want to call it “solidarity,” I can’t stop you.

These public health professionals do hold one idea with which I am in full agreement: that which we call the health care “system” accounts for only about ten percent of our health care. The rest is due to a complex of environmental factors. Dr. Yancey emphasized schools, which she asserts poorly serve certain communities. I certainly agree with this, but the schools are already a government monopoly in the U.S., so I hardly see how the failure of government schools, to date, supports an argument for a similar take-over of health care!

But the public health establishment poses a bigger challenge: everything in our environment has an impact on our health status. Furthermore, our competence at defining and measuring these impacts is proceeding at a far faster pace than our ability to do anything about them. If we accept that government is responsible for anything that impacts our health, then there’s nothing that it can’t control.

And people still wouldn’t be universally healthy – not even if they put us all in cages, fed us kibble and made us run on large hamster wheels for a couple of hours a day!

Let us speculate: did Sebelius want to make sure that you had no doubts about it – or maybe make up in case you missed the president’s address to the American Medical Association? In this meeting, as the president faced an audience of conservative doctors (a dwindling, increasingly unrepresentative sample of practicing doctors in America), President Obama reassured them that he would personally guarantee that doctors would continue to have the pleasure of dealing with for-profit private insurers rather than with “government bureaucracies”– European, Canadian or Japanese style, God forbid!

Now, in case you cannot see the president’s point — why you should fear a “government bureaucracy” more than you fear the bureaucracy of your health plan (assuming, that is, that you still haven’t lost your coverage because you lost your job, or that your coverage has not gone up so much that you can no longer afford your share, employer provided or not) — White House Chief of Staff Rahm Emanuel intends to clarify just that. According to Emanuel, the president is against single payer (even if he was for it as a young and idealistic senator) because what matters is “not the means but the objectives”, namely, cost control and universal coverage (yes, he said this with a straight face).

What? You don’t see the relationship between controlling costs and covering everybody, and opposing single payer, i.e., Emanuel’s argument? Again you are not alone; neither do I.

A critique of Emanuel’s answer I found in cyberspace (well worth reading) may provide a hint of what makes our democracy tick. The gist of this critique is that Congress and the White House do not want to hear that single payer health care – a mere change in financing, not in delivering, health care — would save money, cover everybody and set the right system of incentives to improve the quality of care. Which is why the White House and most members of Congress are rather pleased that the Congressional Budget Office is not analyzing it as it did with other proposals (e.g. “public option choice”), and they are even getting in the way of this analysis. (After all, who would want to hear that?)

What the CBO has said about current proposals for reform is consistent with the assertion that none of the “traditional” explanations for our high costs work, really: the Japanese, among many others, have higher utilization rates (visits to doctors, MRIs, etc) than we do, greater percentage of elderly in the population than we do and, to our knowledge, do not eat more broccoli than we do. And yet, they pay 50% of our price tag (per person) when it comes to health care [PDF].

Why? Because they collectively foot their medical bills (“social insurance” in health policy jargon), which enables them to cut costs through reduction of administrative overhead, bulk purchases and cross-subsidization, as I explained in my former posts, and because they take shared responsibility seriously — that is, everybody has to pay into the system, but only a proportion of their income, because the point of the system is precisely that you not go bankrupt, and receive medical care according to need, not ability to pay. So do Germans, Britons, Canadians and so forth.

So, it looks like to achieve health care reform we cannot wait for the winds of Washington to blow favorably in the direction of the American people’s welfare. Rather, the American people will have to make these winds blow all by themselves. And why not dream big, with audacity? (How about “The Audacity of Hope?”)

Thankfully, Americans have some historical precedents; after all, Martin Luther King did not say, “I have a dream, but it is not politically feasible right now, so let us just settle for equal rights for some as a step towards equal rights for all when the time is ripe.” And health care reform is already a matter of civil rights, as well as of economic sanity and survival.

If you wish to join, two loose coalitions of single payer supporters, Single Payer Action and One Payer Now (among many others), invite you to sign up so that they will inform you about health care reform, gather your signature for petitions and organize rallies that you can attend.

My guess is that when enough people lose their jobs and are dumped from those plans that, according to President Obama, “the majority” of Americans “like” and “want to keep,” and find out that they have the “choice” to buy good yet expensive coverage, affordable yet skimpy coverage, pay a fine or request a “hardship waiver,” enough of us will be pissed off and we’ll get single payer.

POSTSCRIPTUM: Nope. David Leonhardt still hasn’t read my third posting. Clearly, he still seems incapable of “imagining” any other way to cut the skyrocketing costs of health care than going after you, the patient, and to a lesser extent against those brave health providers that cater to poor people.

So, be prepared to have your employer benefits taxed (especially if they qualify as the “Cadillac” sort, buy a policy (whether it will actually protect you from medical financial ruin or not) and see major cuts in community clinics serving Medicaid and SCHIP patients.

Wonder why Leonhardt forgot to first eliminate, say, high CEO salaries at for-profit health insurance companies, amounting to $1.75 billion that went to 20 people in the private health insurance sector in 2002, and a total annual compensation of $1,153,864,691 — including stock options — going to the highest paid executives in 2002 [PDF]? Now there are some costs that could be really cut so that the money can buy health care for the American people!

And, if you are puzzled and upset as I am, click here to write your letter to the editor of the New York Times and comment about Leonhardt’s omission. Having your voice heard makes a difference.

My colleagues Ellen Wu and Lark Galloway Gilliam appropriately spotlighted the state’s fiscal crisis and the potential impact of the budget cuts proposed by Governor Arnold Schwarzenegger. The health care cuts could deny coverage to nearly two million Californians [PDF] and have severe impacts on a range of health programs, services and providers on which we all rely. Health Access has a one-page flyer that summarizes all the health cut proposals [PDF] by the Governor.

California has better budget choices, including raising the taxes and revenues needed to prevent these and other devastating cuts. We need to avoid not just the tragic human impact of the cuts, but the consequences to our health system and our economy. For example, we lose two federal dollars for every dollar we cut to Healthy Families, the State Child Health Insurance Program (SCHIP) that insures low-income kids which is proposed to be eliminated. So for every dollar the state cuts, that’s a three dollar cut to our health system and our economy, and a greater multiplier effect beyond that.

The loss will be even greater with the passage of national health reform. In the proposals in Congress, Medicaid and SCHIP is the foundation for additional coverage expansions—and these cuts would attack that foundation in California. We would further undermine our state’s ability to bring in federal dollars and take advantage of the benefits of reform if we undo our health system’s infrastructure at this crucial time.

But Californians should not just prevent steps backward; we should take some steps forward at the state level. State-level bills on comprehensive health reform have stalled for the year, as legislators focus on the budget crisis. But there’s still progress on specific health reform on a policy level.

One bill, AB786 (Jones), sponsored by Health Access California, would set some basic standards in the individual insurance market, and help weed out “junk” insurance that gives coverage a bad name. Lark Galloway Gilliam spotlighted this issue when asking: what’s the value of coverage, anyway? We’ve talked to many patients who find out that their insurance doesn’t cover very much—often not until it’s too late. That’s why there needs to be better information and labeling of insurance products, so consumers can comparison shop and know what they are getting.

Along with the provisions of the bill which I detail at The New Republic’s The Treatment — a useful blog for those following the national health reform debate — there’s research that indicates it is impossible for consumers to figure out exactly what their policy does and does not cover. And even then, consumers aren’t actuaries, and thus have limited ability to figure out what risks they need to insure against.

The bill, authored by Assemblyman Dave Jones, chair of the Assembly Health Committee, takes a needed step toward helping consumers comparison shop in the near term. But the provisions have been part of comprehensive health reform in California, and are being considered in the federal health reform conversation. Even in a bad budget situation, California can make progress in health reform.

So, if we go to a public plan, I have a list of minimal requirements that must be met:

1. Health decisions must be left in the hands of an independent authority, including decisions about what and whom to cover, how benefits are managed and the premiums

2. There would be a statutory requirement that government cannot use its revenues to support the public plan

3. There would be no hidden subsidies relative to private plans, i.e., :
a. Pays taxes on any profits;
b. Has capital requirements like anyone else
(Fannie Mae and Freddie Mac got very big precisely because of #3.) This also means that if the government wants to pay the premiums of a particular group (say 55 to 64 year-olds), they have to offer a voucher that can be used in private or the public plans.

Looking at this list–and thinking about the current situation–I realize this may be untenable. This government just gave $50 billion to General Motors. If the public plan gets into trouble because it covers everything - just like Medicare - then is it reasonable to assume they won’t be bailed out?

The bottom line is that I don’t see a way to ensure a level playing field.

Unsurprisingly, President Obama traveled to the polar opposite of McAllen: Green Bay, Wisconsin. At a rally of the faithful, Mr. Obama proclaimed that “we” is the federal government. Through various levers (especially health IT, a boondoggle for high-tech companies), his health reforms would bring the whole country up to the health care standard of this high-quality, low-spending community.

The Obama White House has succumbed to the fundamental fallacy of socialism: believing that the government can collect information, analyze it and then command its citizens to act in accordance with the government’s conclusions. In this case, the information is the Dartmouth Atlas, a well-known body of research that documents variance in Medicare spending and outcomes across the country. While places like Green Bay demonstrate low spending and high quality, places like Miami or Los Angeles demonstrate the opposite.

Advocates of the practice of medicine by government dramatically oversimplify the implications of the Dartmouth research, claiming that the variance is caused by too much medical care delivered to patients who actually suffer from it. If the government just commanded all medical providers to deliver the same volume of care nationwide, we’d cut health spending by 30 percent.

Oh, really? If President Obama believes that he’s got enough charm to convince Miami’s seniors that Medicare is going to cut back their access to care by 30 percent (sorry, we’ve already done all the coronary artery bypass grafts allocated to this ZIP code for this year), then he’s got political guts – that’s for sure.

Nor are scholars united on the reason for the variance, which is unexplained by medical necessity. The Dartmouth researchers lean towards provider-side reasons. Like most academics, they tend to dismiss the idea that patients “demand” health care. Instead, they do what their doctors tell them. So, the volume of care delivered depends on doctors’ financial incentives and their local culture (for example, following the doctors from whom they have learned).

But the truth is more complex. Greg Scandlen, currently a health policy analyst, was working at Blue Cross Blue Shield of Maine, the source of much of the original data. The data indicated that women in Lewiston, Maine were something like three or four times more likely to get a hysterectomy in their lifetimes than were women in Wiscasset, just thirty miles away. Mr. Scandlen points out that Lewiston was heavily French Canadian and Roman Catholic, while Wiscasset was almost entirely Yankee Protestant, concluding that women in Lewiston were using hysterectomies as a form of birth control after having six or more children.

Furthermore, in the journal Health Affairs, Dr. Richard Cooper analyzed data which included private health spending, as well as Medicare spending, and concluded that more spending did result in better outcomes. Dr. Cooper’s findings indicate that it is the centrally controlled Medicare program that has trouble paying for quality, not the 1,800 private insurers that compete against it.

Health care is far too complex for a central government planner to reduce costs without harming quality, in a quest to “cover the uninsured.” Greater choice and higher quality in health care will come from less government control, not more.

In an earlier post, I urged readers to consider the sacrifices they might be willing to make in order to assure a fairer, more efficient and higher quality system for all. The lack of response to that post, and to the cost containment topic more generally, confirms that these are not popular or easy subjects. Yet we all must engage. Achieving sustainable long-term reform depends on converting the vague goal of “shared responsibility” into concrete consensus about how costs will be allotted and benefits assured.

So I would pose a few more hard questions:

• For patients with insurance that covers virtually any service you ask for or your doctor suggests: Are you ready to pay more for services that are often ineffective, or that provide reassurance but little clinical benefit? (A recent report [PDF] by the Center for HealthCare Decisions helps tease out what matters most, and what matters least, for coverage.)

• For workers covered by an employer-sponsored health plan with generous benefits: Are you ready to pay more a) in premiums, b) when you get care or c) through taxes?

• For doctors and hospitals that serve primarily privately insured patients: Are you ready to have payments tied to health outcomes, not the volume of services you provide?

• For health plans whose business models rely on developing complex products that “cherry-pick and lemon-drop:” Rather than competing based on the health status of the members you attract, are you ready to compete by demonstrating and developing incentives for health care quality?

President Barack Obama says, with respect to health insurance, “if you like what you’ve got, we’re not going to make you change.” Over the long term, it will be hard to deliver on that promise. What’s more, considering the flaws in quality, affordability and access that characterize U.S. health care and coverage today, it may not be desirable. What makes me, you or any other individual happy is undoubtedly important. When we share resources, however, a broader perspective – thinking not only about private interests but public good – is important too.

Prevention is a good example.

Improvements in the health of middle and older aged Americans during the last half century are indisputable products of investments in medical technologies and successful public health efforts to encourage prevention.  Efforts to curtail smoking, the development of medications for hypertension and, more recently, statins (cholesterol lowering drugs) are excellent examples.

But there are storm clouds on the horizon.  With a growing elderly population — and a larger baby boom generation approaching retirement — the prevalence of chronic diseases will rise.  If current trends continue, health care costs will experience a commensurate increase that will consume an ever-increasing share of national income.  The future liability of the Medicare program alone is estimated to be $24 trillion over the next 75 years, absent any policy changes.

With this renewed focus on health care costs, policy makers have begun to consider prevention as a place to invest — not only in providing more services but also in research to identify better treatment strategies.  Medical or public health interventions in the form of primary prevention should, in theory, have the capacity to slow or reduce the rising prevalence of chronic disease, and simultaneously attenuate the downstream spending associated with it.  Thus, if there is a ‘magic bullet’ for rising costs of health care immediately available, basic improvements in population health brought forth by existing treatments may be the best and most economical option. 

Unfortunately, when it comes to costs, there is one sad fact that works against prevention – it saves lives.  And when people live longer, they spend more money.  The best estimates of prevention show that it could save a modest amount of money over a lifetime (maybe 3%).  More importantly, however, it can lead to a life that has less disability and more years of active lifestyle.  So, while prevention may not save a lot of money, it will make a lot of people feel better, and that, after all, is the point of health care.