Dr. Tom Roberts - June 05, 2009
Health Care Reform
Last week, many of us in Montana had the opportunity to attend, participate in, or read about Listening Sessions. These meetings on health care reform were held around the state, mostly in our small towns. Staff of senator Max Baucus were there to support Max’s efforts at leading reform nationally. We also heard from people involved locally in providing health care. Based on my experience here in Missoula, and reports from other parts of the state, people who attended the meetings are more than ready for change. The message to take back to D.C. is a concern that current reform plans don’t go far enough.
If Max’s committee continues on the current path, we can anticipate a Massachusetts style insurance exchange. Health insurance will be much more tightly regulated. Minimum benefits will be put in place. It seems likely that every person will be required to obtain health insurance and nobody will be denied coverage. Pre-existing conditions won’t affect the cost of the insurance. Those who can’t afford it will be given a subsidy. Currently debate has developed around whether a public, government run health plan will be put in place along side of the private plans. For those who believe that health insurance companies are at the root of our current problems, this is an attractive alternative to private insurance. Some look at a public plan as the first step in the eventual takeover of health care by a government run single-payer system. Pressure seems to be mounting in Washington, and at this point, despite severe Republican objections, I suspect a public plan will be part of the reform process this year.
However the public plan option develops, it will be important to keep our eyes on the real goals. Health care reform is certainly about access. As we begin to regain our moral compass under a new administration, we seem to realize that it is no longer acceptable for the richest nation in the world to deny access to health care because of a person’s inability to afford it. We understand the need to replace our inefficient and inequitable insurance system with a simple straightforward one that subsidizes the poor and requires everyone to pay their fair share. Whether a public plan, competing with private plans, will actually improve access has yet to be shown. Massachusetts has provided health care coverage to 98% of their population through a combination of existing private plans and an expansion of Medicaid.
But a reformed health care system is also about cost and quality. Without close attention we could end up, like Massachusetts, with an expansion of our current system that looks increasingly unaffordable. The problem is that we have become used to thinking that high cost health care is not only inevitable, but necessary for improved quality. What is becoming increasingly obvious is that both of those assumptions are wrong. Low cost, high quality medical care is available in many areas of the country, including western Montana. Medicine it turns out is practiced differently, depending on where you live. As Atul Gwande points out in an article in this week’s New Yorker Magazine, which is available for free on line, people living in McAllen, Texas in 2006 spent about twice as much on medical care as the national average. This is about 2 ½ times what we spent on medical care here in western Montana, and twice as much as in Rochester Minnesota, where essentially all care is supplied by the Mayo Clinic, a relatively low cost but very high quality system by anyone’s standards.
Many areas of the country spend a lot of money without improving the quality of care, while others achieve affordable care while at the same time maintaining or actually improving quality. This variation is widespread and is not associated with a healthier lifestyle or lower rates of illness. It is not dependent on the type of insurance available in that area. This would argue against either a public plan or single payer Medicare for all as potential solutions for cost and quality control.
Low cost, high quality health care is associated with organized systems of care. These are places where providers work together not independently of each other. It is also associated with lower numbers of specialists and hospital beds, and with higher numbers of primary care providers. Payment incentives in our current system do not encourage health. Hospitals are paid when their beds are full, not when people are healthy and the beds are empty. Specialists make more money when they do more things to people, not when they figure out how to do less. Primary care providers are not paid to keep people healthy, out of the hospital, and away from expensive and unnecessary tests.
Real health care reform means fundamental structural change in how physicians, hospitals and others are organized to provide care. It means changing incentives so that providers are rewarded for cost effective, high quality care, not for figuring out the most expensive way to take care of a problem. Real reform means focusing on the health of our population and effectively taking care of chronic disease. These are our challenges. How we begin to meet them now both locally and nationally, will determine not only our physical health, but also our mental and fiscal health in the years to come.
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