Friday
April 16, 2004
It's been called the best system in the world by some. Others say that American health care lags far behind that of most other western nations, and they cite mortality rates and outcomes data to support their view. Still others contend that U.S. health care doesn't constitute a "system" at all, but is rather a hodgepodge of treatment and delivery methods, federal and state regulations, quality measures and reimbursement and funding procedures, all of which vary dramatically from one part of the country to another.
But even among these disparate viewpoints a consensus is emerging that the way health care works in this country must change if it is to meet the needs of an increasingly diverse and aging population. That realization seems for the first time to be taking hold across the spectrum of health care stakeholders, from consumers to payers, from providers to policymakers. And prominent representatives from each of those groups say that there may be no better time to undertake a national discussion of the issue. "This conversation will take place as part of the presidential campaign," says AHA President Dick Davidson. "We want as much debate as the candidates can stand."
But are we Americans really ready for health care reform? And is there the political and popular will to make it happen?
The crux of the discussion will be how fundamental health care change should be. Some argue that the current set-up is effective and that a tweak here and there is all that's needed. Others insist that a broader approach is called for, with a goal toward a more accessible, equitable and sustainable system. Although he supports comprehensive change, Reed Tuckson, a senior vice president of United Health Group, Minnetonka, Minn., could be speaking for both sides when he says "the status quo is the least desirable outcome."
Driving the discussion is the issue of access and coverage. More than 43 million Americans are without health insurance today. The Heritage Foundation and others predict that number could climb above 60 million by the end of this decade. Many are the so-called working poor, whose employers are unwilling or unable to absorb skyrocketing insurance premiums and who cannot afford to pay a greater share of their coverage costs. Add to that a growing number of middle-class workers who at one time or another find themselves unemployed and without insurance--80 million Americans lack coverage for some period over any two-year span, according to research by Penn State economist Pamela Farley Short. Then there are the aging baby boomers who in the near future will stress Medicare to the point of collapse absent a big turnaround in the federal budget or painful cuts in benefits.
No wonder that in survey after survey the public ranks health care at or near the top of its concerns. In the AHA's own survey of 800 voters, 27 percent of the respondents ranked health care as a leading concern, on par with terrorism and topped only by the economy. It's no coincidence that this year's presidential and congressional candidates have made health care reform conspicuous planks in their campaign platforms. Even if it's more positioning than substance at this point, leaders within the health care field say that at least the issue is on the table and they are seizing the opportunity to turn the rhetoric into real change.
But health care reformers are nothing if not realists. Ever since the spectacular implosion of President Clinton's sweeping health reform plan a decade ago, most policy-makers have pointedly avoided calling for a complex overhaul of the system. Instead, the strategy has been an incremental approach in which any effort to enhance access to care focuses on a specific, limited segment of the population. The State Children's Health Insurance Program, for example, was designed to help kids in uninsured families get the care they need. Although SCHIP has been effective, current budget woes are forcing some states to cut outreach efforts.
The successes and setbacks of SCHIP and other programs intended to expand health care coverage point up the drawbacks of incrementalism, critics say: Unless we can come together around a shared vision, create a comprehensive and cohesive strategy and commit the resources to achieve our goal, we will never make real progress in expanding access and coverage.
"I'm a recovering incrementalist," says Quentin Young, M.D., national coordinator of Physicians for a National Health Program, a group advocating a single-payer system. He says incremental efforts are difficult for the public to understand, complicated for both providers and consumers to participate in, and subject to political shifts and the vicissitudes of the economy like those now threatening Medicaid programs in many states. "Incrementalism fosters disenchantment with reforms, or worse, the rejection of government solutions," Young says.
Tuckson strikes a similar chord. "I don't believe in incrementalism; carving out pieces won't be successful," he says. "Comprehensive strategies are needed to get essential health care to all Americans."
Tuckson served on an Institute of Medicine committee that in January published "Insuring America's Health," the final in a series of reports examining the issue of uninsurance. One of the key findings is that despite 20 years of federal incremental efforts, the percentage of uninsured Americans has hovered around 16 percent of the population. That's why many of the committee members rejected the concept of incrementalism, according to Shoshanna Sofaer, a health policy professor at Baruch College in New York City.
"Looking back over the history, [our sense] was that incremental solutions, if they're targeted at a specific age group, if they're targeted at a particular disease ... just don't work," Sofaer said during a panel discussion she chaired in January. The number of uninsured Americans keeps growing, she says.
The IOM report called for the president and Congress to develop a strategy to achieve universal coverage by 2010; however it purposely avoided recommending specific, detailed solutions, choosing instead "to articulate evidence-based principles that could be used in assessing coverage expansion proposals and in designing new ones," Sofaer said.
While health care advocates agree that universal coverage is an ideal worth pursuing, many say that achieving it is another matter.
For full coverage to take place, all the stakeholders have to find common ground, says former Health and Human Services Secretary Donna Shalala, and that doesn't seem likely anytime soon. Sister Mary Roch Rocklage, former AHA chair and a board member of the Sisters of Mercy Health System, St. Louis, agrees. "Each stakeholder is looking at his problem and how he can solve it. Providers, consumers, payers--we are all playing in our own back yards." Another problem is that Republicans and Democrats have vastly different strategies for solving the coverage crisis. Conservatives want individuals to take the lead, using tax credits and other incentives. Liberals envision more government involvement.
Perhaps the most vexing problem is how to pay for expanded coverage, especially at a time when federal and state governments are facing long-term deficits. "The harsh reality is that there may never be enough government money," Davidson says.
Of course, some politicians can be expected to dodge difficult issues until public opinion compels them to do otherwise. And up to now, public opinion has not coalesced in one way or another around the issue of the uninsured.
Arthur Kellermann, M.D., chair of the department of emergency medicine at Emory University, Atlanta, attributes that apathy to four myths about the uninsured: That the uninsured get the care they need; that the uninsured do not affect care for the insured; that the nation can't afford to deal with the uninsured crisis; and that the status quo is better than accepting any changes advocated by an opposing faction.
Kellermann and others say that in fact, the uninsured place a disproportionate burden on health care resources because they lack access to wellness programs, primary care and continuity of care. Therefore, they tend to be sicker when seeking care and their health care encounters tend to be more costly, such as visiting emergency departments. By overcrowding EDs, and because some physicians are reluctant to expose themselves to liability from treating higher acuity patients and therefore refuse on-call shifts, access to care for the insured can be compromised.
A 2003 IOM report concluded that the lack of coverage costs the uninsured themselves $65 billion to $130 billion annually, a figure including lost wages and lost productivity, among other things. They suffer this loss because they are sicker and die earlier than insured people. The authors of "Hidden Cost, Value Lost: Uninsurance in America" argue that paying for the coverage, which the report estimates at $34 billion to $69 billion annually, would be less than the cost of not providing this benefit.
But if uninsurance is indeed gaining urgency with the public at large, it is because it has moved from a do-good notion to one that hits home for average Americans.
"The issue of the uninsured has been an issue of altruism for a very discrete part of the American public," Ron Pollack, executive director of Families USA, a Washington, D.C.-based consumer advocacy group, said during the IOM panel discussion. "And an issue of altruism can only take you so far." Now, as the demographics of uninsurance expand to include more members of the middle class, it becomes a concern of self-interest. "If you take a look at which groups of folks are the ones who are now joining the ranks of the uninsured, they are by most standards middle-class families," Pollack says. "They are working families. Those are the folks who vote."
Even people who have never lacked coverage are beginning to feel vulnerable as employers shift a greater portion of insurance costs to their workers and as insurers and some employers push for so-called consumer-directed plans. The idea is to give workers a limited amount of money for routine health care and the power to determine how to spend it. Advocates of such plans say they will force consumers to finally understand the true costs of health care and, therefore, make more reasonable decisions about the care they choose. Watchdog groups, on the other hand, worry that the plans are another form of cost-shifting that will overburden consumers and diminish the quality of care available to middle-class families. In any case,"the middle class are worried about affordability and that they themselves could be uninsured in the near future," says John Holahan, director of the Urban Institute's Health Policy Center.
However urgent the issue of the uninsured has become, the likelihood that Congress will decide to adopt a national, single-payer health system in the near future is nil. "The people who play around with the single-payer notion are dreamers," Holahan says. "It's a massive amount of money that would have to be redistributed." Even the people who compiled the IOM report recognize that achieving their goal of universal coverage by 2010 will involve a series of steps rather than one giant leap.
Just don't call it incrementalism.
"We are making a distinction between what we call an incremental solution and a phasing in of a more fundamental solution," Sofaer said during the IOM discussion. "We're not at the same place in our health care delivery system in terms of its complexity to be able to do what we were miraculously able to do in 1965 when we passed Medicare one year and implemented it the next."
Gail Wilensky, former HCFA administrator and now a senior fellow at Project Hope, concurs. "Sequential steps can add up to significant change when articulated with a vision," she says.
To establish that vision and rally broad-based support for achieving it, the AHA and others hope to harness the intense attention that health care is getting this election year. Toward that end, the AHA developed "Seven Steps to a Healthier America" (see sidebar, Page 44). "It's a an incremental set of priorities," Davidson says. "If you look at the increments, we can sneak up on coverage."
Or, perhaps it's a matter of semantics. "Instead of talking about incrementalism, we call it sequential reform to get universal coverage," says Michael Rodgers, vice president of public policy and advocacy at the Catholic Healthcare Association of the United States.
Whether they call it incrementalism or sequentialism, reform advocates say the steps to broader health care coverage will be varied and will involve a number of players, from states to the private sector, in addition to the federal government--supporters of a single-payer system notwithstanding.
The IOM report lists four prototype strategies: major public program expansion, a premium subsidy for both individuals and employers, a tax credit for individuals and a classic single-payer option. Mixing and matching is expected.
"In our view, the ideal solution may very well involve a hybrid," Sofaer says.
The key to finding the right hybrid for expanded coverage will be a willingness among stakeholders of all stripes to compromise--an elusive element in previous debates. But market pressures may force action. The Center for Studying Health System Change, Washington, D.C., conducted site studies of select communities and found that stakeholders--insurers, employers, health plans, providers--are realizing their interdependence.
A business coalition at one site found that health care delivery accounts for 18 percent of the community's jobs, helping employers see that when they ratchet down rates, they could damage the local economy, says Len Nichols, a health economist at the center. At the same time, some hospitals in these communities worry whether employers can absorb health care rate increases because wages can't grow that fast. "The possibility for shared sacrifice and a consensual solution exists," Nichols says. "No one thinks there's an obvious solution, but now there's a chance we can have a real conversation, as opposed to 'you pay for my improvement' " He says that unlike 1993 when the Clinton plan failed, stakeholders may be able to agree on what problems need to be addressed.
"During the Clinton proposal, we never had a conversation about what we believed about health and health care," Davidson says. "Now, there's a growing conversation about these issues."
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