How to Afford Health Care Reform

The promise of universal health care - offered in one form or another by almost every presidential candidate - is looking more and more like a big lie. Give us a break. If neither the president nor congress could even bring themselves to expand moderately a highly successful federal health insurance scheme for poor children, how are we ever going to find the money and the political will to join the rest of the developed world and cover everybody?

In the October 25, 2007, New England Journal of Medicine, policy scholar Jonathan Oberlander wrote, "No matter how much momentum it seems to have, no matter how many signs point to change, there is nothing inevitable about health care reform in the United States." He inventories the armory of the status quo: providers' economic self-interest is too great, most people are too content (even if they're not delighted) with what they have, government projects are too suspect, attention spans are too short, Congress is too divided, and nobody can figure out where the money will come from.

Some states look like counter-examples - Massachusetts, California, Vermont, and a few others - by declaring their intention to assure universal health care insurance. In fact, Massachusetts has already solved almost half of its problem, covering over 200,000 more people in less than two years since passing its law. These state-level initiatives likely reflect some important and stable desires in the body politic: to have care for everybody that is both good and affordable. But, we fear, these bold commitments are headed for the same rocks on which national reform has foundered so far.

It's sad, and even sadder because it is unnecessary. No candidate, no political leader, no courageous state coalition, and few, if any, payers have yet realized or (if they realize it) found a way to make salable to the public a scientific fact: the apparent deadlock between assuring the care we need and finding the resources to give it is an illusion. It dissolves, or nearly so, when one understands what "quality" is in health care. The best way to make universal coverage affordable is not to reduce care but to enhance it. More precisely, it is to promise all the care that helps, BUT only the care that helps.

That's because so much of the medical care we give and get today is pure waste - it does not help any recipient, hurts many, and costs a ton. It is technocracy with no benefit, indeed, often with harm. For example, Dartmouth researchers Elliott Fisher and Jack Wennberg have shown that the top fifth of American regions in health care costs per capita spend $3000 per year per Medicare beneficiary more than the bottom fifth, but the highest cost areas have worse outcomes and poorer satisfaction for both patients and doctors than the lowest cost areas.

We estimate that at least 30% of the health care that we pay for today does not work. It shows up as tests and surgical and other procedures we don't need, errors in care that then need correction, complex medications when simple ones or none would do fine, unwanted intensive care at the end of life, avoidable hospitalizations for chronic illness, using doctors for tasks that nurses and others could do even better, and failing to use simple and convenient alternatives to office visits, like email, web-based supports, and the telephone. A lot of the waste is concentrated in care for the chronically ill, the 10% of Americans who use 70% of the care. Patients and families often don't see this as waste. For them, it takes the form of bad experiences: hassles, out-of-pocket costs, complications, dropped balls in their care, and confusion. But, it's all the same: the high financial toll of poor quality - a "lose-lose" proposition. And, when the waste is swept into promises for universality, it all adds up to unaffordability.

Of course, linking quality improvement to universal coverage won't disarm the proponents of the status quo entirely. What is waste for a patient is often income for someone else, and the structures that benefit from Fisher and Wennberg's $3000 of non-value won't go down without a fight. But, surely aiming for excellence, not ineffective excess, can help us get to the social justice and equity that behoove a great nation. We need proponents of universal coverage to realize that, and then we need them to explain to our public that all Americans can have the health care they truly need at a price our nation can afford, if (and maybe only if) we extract and end habits of error, defect, and overuse that help patients not at all.

Donald M. Berwick, MD, MPP, is President & CEO of the Institute for Healthcare Improvement. Howard Hiatt, MD, is Senior Physician at the Brigham and Women's Hospital and former Dean of the Harvard School of Public Health.

Comments

[cloudy]

I agree with those commentors who note the grand unspecificity of the critique of massive waste in the medical field. Even just a handful of LINKS to articles written by these authors or by others pointing to specific instances of waste and legislative strategies to address them would change this article massively.

It may be true that really POSITIVE health care reform, as distinct from the W Bush era MedicareScam, is indeed impossible, as long as the Repugs can filibuster anything in the senate with 40+ senators. But this column doesn't even give us an idea of what kind of reforms WOULD reduce unnecessary costs, so that we could have a program/platform to aim for in senatorial elections against the Repugs.

(And yes, I know Dems are also well-oiled by the health industry, as they are by big oil, etc.). One thing I like about Kucinich's platform for universal single payer coverage in a non-profit health sector is that at least it lays out a goal that would address the problems, even if the pursuit of that goal (like his candidacy) is not likely to bear fruit in the short-term future.

[avergejoe]

How about saving MILLIONS of dollars by getting rid of those whose sole job is to DENY health care!

[tbone99]

Until we begin thinking preventively our health care system will continue to be outrageously costly.Pre­vention isn't just about more Dr. visits - its about seeing our health as our responsibility , not someone elses.That said, how can we properly care for ourselves if we need to work long hours just to provide a roof for families, live in a country in which the enviroment has become laden with toxins and healthy food has been overtaken by the chemical and pharmaceutical industries­.?

[Morcat]

The myth that Americans cannot reform healthcare is based on our current inability to understand and appreciate the power of process. Using evidence to change the system, rather than simply tampering randomly, will work. We have to elect representatives who have some understanding and respect for process and then make it clear to them what we expect in regard to healthcare. As a nurse for over 35 years, I well remember over a decade ago, when the healthcare community purported to embark on a Total Quality Management journey. Turns out, they really didn't mean it. We need to go back and develop a vision and mission for our healthcare institutions that is relevant to the needs of today, then study and rework our processes to serve our needs. Will it take 20 years? Probably more, but it must be done. I remember Dr. W. Edwards Deming predicting precisely the situation we have today. Had we really meant that we wanted quality in healthcare 20 years ago, we'd be farther along today, but we allowed the quality initiatives to be subverted and trivialized by for-profits and insurance companies. Pursuing quality will lead us out of this healthcare mess, but we have to mean it this time.

[barriosbabe]

My husband just got a fairly decent new job (we both work full time) and we can't afford the employer's health plan! It's almost 700 per month and we don't have it.What are you talking about? The only real answer is to get profit out of health care. Massachussetts? It's a disaster, if my family lived there we would be forced to pay $800 per month for no coverage or leave the state (there's an annual 4K pay first provision and we can't afford that either.)

[DavidfromEugene]

One possible source of money could come from the double or triple medical coverage on many Americans. Automobile, Homeowners and Workman’s Compensation Insurance all include medical coverage. If everyone has medical coverage that pays for all necessary medical treatment regardless of cause, that coverage would no longer be necessary. This should result in a savings to those Insurance carriers. Why not split that savings three ways part to the policy holder in reduced rates, part to the Health insurance carrier and part to the insurance company. There would be another benefit to Automobile, Homeowners and Workman’s Compensation Insurance Companies, reduced litigation as there would no longer a need to sue to recover the cost of medical care.

As to encouraging people to seek preventive care (check-ups, immunizations and the like) Have two co-pay schedules one for people who are up-to date with preventative care and one for those who are not.

[PigLipstick]

Hear the details of Dennis Kucinich's plan for a single payer healthcare system and watch the MSM attempt to discredit him to please their corporate masters and keep access to real healthcare out of reach of average Americans;

http://www.kaisernetwork.org/health_cast/presidentialhc.cfm?hc=2418

Then go to the Physicians for a National Health Program website and see how many private physicians are working to implement a national system to deliver healthcare to every American. Stop listening to the insurance industry lies that are causing the death of way too many Americans every year and resulting in economic hardships that have forced far too many American citizens to lose all they have worked for in their lives;

http://www.pnhp.org/news/2003/august/many_doctors_call_fo.php

[curiousasheck]

This system is so broken we can't even get a doctor to tread into "enemy territory" for a second opinion on a family member because of contracts, company loyalty agreements, and competitive factors.

What kind of system is that?

[unfoxworthy]

AND..insur­ance needs to be portable..­.decoupled from employer's benefit packages.

The stagnating effect of having people married to their jobs because of preexisting conditions or the thought of a lull in their coverage for their families is just one more controlling variable included in big business' equation of influence. Employers exploit that benefit just like they do anything else.

With big health care, big pharmaceuticals, and big insurance (and don't get me started on the AMA) entrenched on K Street, we've got to stop their dollar impact on the political system first.

[tslat]

Let's make an analogy - healthcare and education. The value of a free public education is rarely debated by politicians. It is society's belief that a free education system benefits all. You also have a choice. You can opt-out of a public school by sending your child to a private school. The two education systems peacefully co-exist.
Why is the healthcare debate so different? Government exists for the safety and security of its citizens, that's why there's the FDA and a host of other government agencies. I am not arguing the efficency of these entities, but they were created and exist for the public good.
Life is a series of choices. I believe people should be held accountable for their own choices, but who chooses to have a disease such as brain cancer? The healthcare system we have now is in bad shape, waste on all levels and who pays? It is time for some solutions whether it be on the state or federal level.

[moneljhomero]

Finally some constructive comments on health care that didn't continuously focus on universal health insurance, health coverage, affordable coverage, et al. Listen to the candidates from either party and you will NEVER hear them address HEALTH CARE, they all blather on about insurance coverage. This country needs to divest itself from the current, for profit "health care industry" and move to one that, at a minimum:

makes ALL medical professionals qualified to be general practitioners at lesser cost for med training and local service, with advanced/specialty training later

for all intents and purposes, removes insurance companies from engaging in health care activities where their only desire is to maximize profits over rendering of service

stresses individual health education in schools (diet, exercise and hygiene, etc)

actually controls the corporate causes of many health problems (ie, tobacco, alcohol, high calorie/low value foods, and the over abundance of sugar based foods)

polices all health providing entities to ensure quality and effectiveness with an ability to enforce laws pertinent to public safety

Now, this is not a magical fix, merely a pipe dream to consider in today's political environment. Still the idea of real care of amorphous coverage is something that needs more public attention.

[BetterDeadthanRedState]

The only problem I see is finding "gainful" employment for all the salesman, attorneys, advertising agents and accountants who will be out of work once we realize that they aren't providing health care to anyone (quite the contrary) and get insurance companies out of the healthcare business.

[eddiestardust]

Isn't it time to ask a simple question?

Why can't our state legislators just tell health insurance companies.­...

NO more blank checks?

Instead of just rolling over and letting them steamroll price increases on us, why don't we require them to:

REDUCE PRICES?

If they don't then they pay a penalty!

I think it's time that we say enough is enough...n­o more free rides or blank checks!

[Erdgeist]

We will never solve the healthcare problem. We Americans, for the most part, don't give a rat's ass about anyone excepts ourselves. We have been reared to be asocial individuals. Just look around.

The real America is a mean place. We have homeless people, including our war veterans, roaming the streets. Neighborhoods have been taken over by gangs who own the streets of any major city at night. We think nothing of dumping the elderly in rest homes who are forced to lay in their feces.

America is about greed where everyone is looking out for themselves, figuring out some way to take advantage of the credulous.

America, too, is about status seeking where the super rich are getting richer while the middle class are quietly sinking into poverty. This is the dog-eat-dog America. Universal healthcare is not desirable. It bespeaks of a compassionate people. We are not that. Merry Xmas...oop­s...I mean f**k you.

[RnR]

Excuse me...exact­ly *who* is going to determine what health care "works"?

We have, in the current scheme of things, physicians (above reproach - no - almost gods) acting as gatekeepers and deciding what proceedure­s/tests/me­ds are "acceptable" and will be "covered" under your plan.

Sorry...un­iversal, free, health care is easily paid for. Take the medicare part d program away from the private insurance companies and give it to Medicare (the infrastructure is already in place) to administer. Take the profits from the drug program and roll it back into Medicare itself - there you go...all paid for. Not only all paid for, but more profitable because Medicares' administrative costs are much less than the private insurance industry is charging..­.what a surprise.

Do you think that the insurance companies foamed at the mouth grabbing this bullshit part d program because it wasn't profitable?

BTW - tomorrow is the FCC vote on media consolidation. You'd have thought this warranted at least a mention here :(