A Reform Agenda

Almost all of the candidates vying for next year's big sweepstakes have a sound bite or bumper sticker for health care reform. Virtually all of these begin and end with a scheme for getting insurance coverage for everyone by some hook or crook. The opinions that are more to the left look to mandatory coverage and a greater role for the public sector in picking up the tab or, at least, a legal mandate that private sector employers must cover all employees. Not surprisingly, those that veer more to the right would look more to individual responsibility and accountability to inch us toward something that has a semblance of universal coverage.

But all of the impassioned calls for expanded access ignore the dead elephant that one must crawl over to make such a proposal. The real problem with American health care is that the way we do it is wasteful, inefficient and far too costly when compared to every other nation in the world. I increasingly wonder why we want to expand access to a system that is broken in some fundamental ways. Let me grant right here that providing systemic community based primary care to the uninsured would likely produce some savings by preventing some health problems and managing chronic care needs in more effective ways than waiting for expensive and not very effective acute care in an emergency room, or a hospital later in the course of the disease. Having an adult diabetic patient on a regimen of care that prevents the need for end stage renal dialysis is a good thing. But, giving an insurance benefit to this population does not in any way tell me that their health would be better managed given the over-specialized, non-community based system that we have. Perhaps funding community health institutions more extensively and charging them with engaging the uninsured population against a set of health care goals would be more effective.

Regardless, neither of these two approaches will produce the hundreds of billions of dollars necessary to make our health care reasonably priced. To do this we will need to look at the orientation that the entire system has toward the organization and delivery of care to everyone, insured and uninsured. There are four big domains where the problem resides. They are all interrelated.

Acute care treatment for chronic disease - America has the best acute care services of any nation in the world; the most highly specialized practitioners, the very latest technology and the greatest willingness to pay for these services. The crash cart mentality seeps into every aspect of our system. Unfortunately it is too expensive, produces less than optimal outcomes, and is simply not sustainable economically, socially or morally. The reason the National Health Service in the United Kingdom can insure everyone and produce better overall outcomes for forty cents on our dollar is because they refuse to medicalize chronic disease and because they manage health care in the community rather than the hospital. This is not an argument for "socialized" medicine, but it is a call for doing those things we know work for people with chronic disability and disease from diabetes to congestive heart disease in ways that keep them out of the hospital and specialized care which we so handily arrange near the end of life.

Underinvestment in primary care - Every other system in the world - you know the ones that provide care to everyone - has comparable outcomes, achieves them for a fraction of what we spend, and is dominated by primary care, usually in just the reverse ratio of primary care to specialty care that we support. We, on the other hand, have arranged to indebt our students, pay specialists more and drive the next generation of providers into sub-specialty careers at a ratio of something that is approaching three specialists to every primary care provider. This is not a plea for more pediatricians, geriatricians, family docs and general internists, though that would be nice. This is a call for creating a community based, market segmented, and technologically sophisticated set of focused primary care models that meet consumer expectations for service, price and quality. If primary care physicians can lead this revolution, I am all for it, but the needs are so great that I would be happy if it comes from community clinics, Wal-Mart, providers in India and Costa Rica or Cuban trained docs that arrive here across the border before the wall goes up on the Rio Grande. We need to invest in primary care, but not our father's primary care, especially if our father is Marcus Welby, M.D. Primary care needs to be reinvented, not improved.

Misaligned funding - Each profession and institution creates its own context for care, vocabulary and value. These traditions are over a hundred years old in many cases and they now are reinforced by a financing scheme which represents the sixth largest economic undertaking on the face of the globe. Two trillion dollars is reinforcement of a powerful kind. To change health care in America the patterns of funding will need to be realigned to support the goals we desire as a nation. The problem is that we have no mechanism for accomplishing such realignment. Market mechanisms, the current fancy for directing our social preferences, simply don't work in the health finance scheme we have. There is not enough consumer information or choice to discipline the existing providers, and the barriers to new competitors entering to offer alternatives are still pretty formidable. We don't trust public decision making around health care. This even though public systems like the Veteran's Administration deliver high quality service that increasingly meets service demands. All that is needed to shut down any such proposal for change is to conjure up the image of the U.S. Postal Service delivering our health care along with the mail. Personally, I like the service and quality I get from the USPS for the price they charge and I have less anxiety about the delivery of my first class letters than about the probability of contracting a nosocomial infection while in the hospital.

Lack of public engagement - Structuring health care funding in a way that produces the radical changes needed in our health care system will require a new mechanism for achieving public consensus around the outcomes we desire from health care, how we are to achieve these outcomes, and the ways in which we will combine public and private health care. This will require a new method of reaching decisions about health; one that re-engages the public as patients, but also as active consumers and citizens. We reach decisions about the direction and funding of public institutions every day; such as when we give our preferences regarding public schools. Local, participatory structures are a part of the American political genius. We need to apply these structures to our health care system. This is our most pressing public need.