Four actions are needed for health care reform

Trenton (N.J.) Times, Wednesday, August 26, 2009

BY NEIL WEISFELD

"Are you for or against health reform?" This is becoming a defining question for health professionals and analysts, as well as for senators and members of Congress. All will preface their answer by saying, "It depends what you mean by "health reform.' " Here's what everyone should mean.
Four types of fundamental reforms are desperately needed.
First is the need for overall cost control. In 2007, the nation spent $2.2 trillion on health care. That amounted to more than one-sixth of the entire gross domestic product (GDP), or $7,421 per U.S. resident. These unimaginably huge numbers are steadily rising.
The need for cost control is especially severe among public-sector programs. Medicare, Medicaid and other federal and state programs account for nearly half of all health spending nationwide -- partly because elderly and disabled (Medicare) and poor (Medicaid) people tend to be sicker and need more services than others who are insured. Soon, the federal government will be spending more on health care than on everything else combined, from national defense to education to law enforcement.
Analysts sometimes say that the system of steadily rising costs is "unsustainable." That's a pretty way of saying that, someday soon, the health care system will experience turmoil similar to the 2008 collapse of the financial system. Think of thousands of hospitals suddenly closing, along with physicians' practices and other health care settings, as their payment pipelines dry up. Think of the ranks of the uninsured multiplying, as Medicare, Medicaid and private insurers slash benefits. We need orderly cost control to avoid chaos.
The second needed reform is universal coverage. The disgraceful fact that several tens of millions of Americans lack health insurance undercuts any claim that the U.S. economy treats people fairly -- especially when compared with other industrialized countries. Particularly unfair are restrictions for "pre-existing conditions" and other insurance company tools that leave families without coverage just when they need it most.
Third is the need to start to craft a clearer, more consistent set of rules for allocating health insurance benefits. For example, tough choices involve access to organ transplants and other scarce but life-saving technologies.
Tough choices must be made, too, in deciding whether insurance should pay for treatments that are popular but probably have no clinical value, for highly expensive new drugs (often no better than established ones), for new and experimental treatments, for genetically tailored personal care, for effective treatment for substance abuse, and for controversial reproductive services (abortion, birth control, infertility treatments, impotence drugs). Should certain benefits be available mostly to individuals who are younger, healthier, better employed, more educated or wealthier?
Although not yet widely obvious, the need for clearer benefit rules will become far more striking as cost control takes effect and medical technologies continue to advance. Phrased another way, we already ration care, but without any rulebook -- some Americans get these services, and some do not.
Under any set of rules, no one will be happy with every decision that's made. What's vital is to develop, and keep refining, a system that reflects a basic consensus in national values. Otherwise, there will be no trust in the health care system.
The fourth and final needed reform is to sharply improve quality of care. Health policy analysts tired long ago of hearing that the United States has the best care in the world when the data say otherwise. We have too many negligently caused deaths (about 100,000 per year!), too much inconsistency in treatment, too much duplication and too many unnecessary procedures performed by overpaid specialists.
Meanwhile, we don't have enough primary care, disease prevention, health education, quality improvement, mental health care, oral health care or coordination of services. Simply put, we aren't getting enough return for our many, many health care dollars.
Better quality would mean that physicians and other health professionals would work in larger practices that provide integrated services. It would mean addressing the health of populations instead of just individuals. It would mean better compliance with professionally developed clinical guidelines. It would mean focusing on health instead of sickness.
How do the health reform measures put forward by President Obama and the congressional Democrats stack up against these needs? They do an excellent job at No. 2 -- universal coverage. They do remarkably little to meet the other three needs.
That's far better than their Republican critics who, through the years, have consistently supported the worsening status quo.
Neil Weisfeld is a principal of the consulting firm NEW Associates, LLC, Princeton.