Forces calling for Healthcare Reform Now are gaining momentum. I share their sense of urgency—assuming that they are talking about the “reforms” needed to create an effective, affordable, patient-centered health care system. But if they simply mean “universal coverage,” I have to disagree.
Giving every American a piece of paper labeled “health insurance” will bail out a health insurance industry desperate for customers. And it will help drug-makers, device-makers, and medical-equipment makers. But it will not solve patients’ problems. What Americans need is not health insurance, but rather effective health care.
A stunner of a story in yesterday’s Washington Post makes it clear that today we are pouring money into a health care system that does more for the health care industry than it does for patients.
“We're not getting what we pay for," Denis Cortese, president and chief executive of the Mayo Clinic, told the Post’s Ceci Connolly. "It's just that simple."
"Our health-care system is fraught with waste," added Gary Kaplan, chairman of Seattle's cutting-edge Virginia Mason Medical Center. According to Kaplan: “As much as half of the $2.3 trillion spent today does nothing to improve health.”
“Not only is American health care inefficient and wasteful,” declared Kaiser Permanente chief executive George Halvorson, “much of it is dangerous.”
This is a startling indictment, and one that health care reformers should heed.
“There is a broad consensus on what should be done,” writes Connolly, a health care journalist who knows her subject well. The system needs structural reforms which include “realigning financial incentives, coordinating care, researching what treatments work best…and most daunting but perhaps most important, saying no to expensive, unproven therapies.”
Therapies that have not been fully tested harm tens of thousands of Americans each year. Consider this: 10 percent of all drugs approved by the FDA from 1975 to 1999 were later withdrawn from the market or “black-labeled” to warn of risks.
2009: Fund Medicaid, Expand SCHIP and Begin Making Hard Decisions
What can Congress do next year? First, legislators should expand SCHIP and provide additional funding for Medicaid so that more low-income families are covered. Granted, these programs are no better than the rest of the system—indeed, because the fees Medicaid pays health care providers are so low, care is often sub-par. Yet, inadequate as they are, at the moment these programs are all we have to offer our poorest citizens at a time when they will be hit hard by the hurricane ripping through the economy.
But this does not mean that we should throw good money after bad by paying healthcare insurers billions of dollars to shove millions of uninsured and underinsured middle-class Americans into an over-priced, broken system. The insurance industry wants reform that requires every American to buy insurance. If we do that, we will be stuck with a larger version of the mess we have today. And at that point, it will be all but impossible to make the structural changes that we need to protect patients. By delivering captive customers to for-profit insurers, drug-makers, device-makers equipment makers and for-profit hospitals, we fund the lobbyists who will fight meaningful reform.
But there are steps that Congress can take next year to make safe, effective care more affordable for everyone:
- Allow drugs to be imported from Canada, putting pressure on pharmaceutical prices. (Obama has indicated that he plans to do this.) Simultaneously, Congress should consider legislation that would let Medicare use its clout to negotiate for discounts on drugs and devices which now account for fully 16 percent of the nation’s total health care bill. Private insurers would follow Medicare’s example, and before long everyone would be paying less.
- Insist on unbiased medical evidence showing that a new product or procedure is more effective than a less expensive product or service already on the market. Today, the FDA requires only that a sponsor show that its new entry is better than a placebo—i.e. that it is better than nothing. This must change. The FDA also should demand that manufacturers follow through on monitoring the long-term safety of a product after it is on the market. Finally, Medicare should require similar evidence before agreeing to cover a product or procedure. (Today, private insurers follow Medicare’s cues when deciding what to cover, so this would help keep a lid on insurance premiums in the private sector as well.)
- Raise the fees Medicare pays primary care doctors, geriatricians, family doctors, and palliative care specialists for services that can reduce the need for expensive, high-tech medicine. At the same time, trim the fees Medicare pays for services of marginal value. We already have identified a wide range of products and services that provide little benefit for many patients—and in some cases, do more harm than good. They range from cholesterol-lowering drugs that can lead to painful side effects for patients over 65 to unnecessary angioplasties (in cases where medication and exercise would be more effective); MRIs for back pain (when physical therapy would provide much better value for our dollars); and PSA testing and treatment for early-stage prostate cancer, which the National Cancer Institute no longer recommends for average-risk men over 50. Private insurers model their reimbursements on Medicare’s fee schedule; once again, Medicare reform would reduce costs for everyone.
These are just a few of the reforms that Congress could put in place next year to make healthcare safer while simultaneously putting a brake on runaway health care inflation.
Why Universal Coverage Will Take Time
It is worth remembering that, even before the economy began to implode, Obama said that he aimed to accomplish health care reform “by the end of my first term.” This was a reasonable goal; if we take steps to contain costs and lift quality now, it is still achievable.
Insiders who understand U.S. healthcare know that creating a system that delivers effective, safe and affordable care to everyone will involve making some difficult decisions about what works and what doesn’t. As the Post observes: “Since Obama's victory, official Washington has been racing to demonstrate its seriousness about expanding health coverage to every American, while at the same time improving the quality of care. ‘But few of the politicians talk about the difficult tradeoffs that will come with any real reform,’” the article notes, quoting Virginia Mason’s Kaplan.
If reformers want sustainable, patient-centered healthcare, Congress must squeeze the hazardous waste out of the system—and this will require taking on a for-profit health care industry that is reaping billions from the status quo.
We have no choice. The experts agree that between one-third and one-half of the $2.2 trillion we now spend on health care is squandered on ineffective, sometimes unwanted procedures, unnecessary hospitalizations, and over-priced, drugs and devices that are no better than the less expensive products that they are trying to replace. And this isn’t just a waste of resources.
Any medical treatment, no matter how simple, carries some risk. Whenever a patient undergoes an unnecessary procedure he or she is, by definition, exposed to risk without benefit. In the worst-case scenario, an unnecessary hospitalization can result in a fatal medication mix-up or a gruesome surgical site infection. Each year, as Shannon Brownlee reports in Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, an estimated 30,000 Americans are killed by what doctors call “iatrogenic disease”—disease caused, inadvertently, by medical care. Thousands of others are seriously injured.
We are saddled with a health care system designed to put the desires of the health care industry above the needs of patients. David Mechanic sums up the challenge we face in The Truth About Health Care: Why Reform Is Not Working in America: “At some point we as a nation will have to decide whether we wish to design our health care system primarily to satisfy those who profit from it or to protect the health and welfare of all Americans.”
“Speed is of the Essence”
Nevertheless, those beating the drum for Universal Coverage Now seem to be winning the debate in many circles. The most recent issue of the New England Journal of Medicine offers an example in an article titled: “The Lessons of Success — Revisiting the Medicare Story.”
The authors, Dr. David Blumenthal and James Marone, not only “revisit” the story of how Lyndon Johnson turned Medicare proposals into law; I am afraid that they also revise history. Blumenthal and Marone argue that LBJ fast-tracked Medicare through Congress and that Obama should follow his model: “Speed is of the essence.”
But the truth is that before LBJ became President, John F. Kennedy had worked on Medicare for 18 months. JFK began the fight in January of 1961. By “the end of the 1961 session of Congress, the tempo of the Kennedy administration's Medicare campaign began to pick up,” reports Peter A. Corning in The Evolution of Medicare—From Idea to Law, a book Corning wrote for the Social Security administration while memories were still fresh in 1969. A few weeks later, Health, Education and Welfare Secretary Ribicoff publicly pledged "a great fight across the land" for Medicare. Medicare was a featured topic around the country in late October at a series of 14 White House-sponsored regional conferences.”
Gallup polls showed public support running as high as 69 percent. “By far the most important cause for optimism during the spring of 1962, though, was the progress of behind-the-scenes negotiations between administration strategists and the members of the Ways and Means Committee,” Corn writes.” Several compromise ideas were under discussion…
“The climax of the public debate came in the spring of 1962. On Sunday, May 20, President Kennedy spoke to a crowd of nearly 20,000 elderly people in New York's Madison Square Garden, while other administration officials addressed similar rallies in 45 cities. The President's speech was broadcast live over three television networks to an estimated home audience of 20 million persons. Two days later, the AMA's Dr. Edward Annis replied in a network speech broadcast from the same platform used by the President, but with the Garden auditorium dramatically empty, to symbolize the AMA's "underdog" stance.” Estimates suggested that 30 million people watched his speech.
Two months later, the full Senate voted on the bill, and Medicare was defeated 52-48. Once again the AMA had steamrolled the opposition. But Kenney had laid the groundwork for passage, both in Congress, where many liberal Republicans supported the idea, and throughout the country.
Surprisingly, Blumenthal and Marone do not mention Kennedy’s work in their NEJM article. This is because they are intent on sending a message to President-elect Obama “speed is essential. Johnson knew this in his bones.” The savvy health advisor will turn to the president-elect the day after the election and tell him, "Hurry up, we're almost out of time for health reform." To reinforce there message, the articles authors must pretend that LBJ fast-tracked Medicare through Congress.
In fact, LBJ inherited a Medicare campaign that was not dead, only dormant.
Following Kennedy’s assassination, LBJ built on the work that JFK had done, using grassroots support for a martyred president to help make his case.
But it wouldn’t be easy, even for LBJ. In November of 1963, he began work on Medicare; in July of 1965. Johnson finally rammed his bill through Congress. This was neither a quick nor an easy process. And it was hardly an example of gentlemanly “bipartisan compromise.”
Johnson threatened everyone—Democrats and Republicans alike. LBJ had spent much of his adult life in Congress. He knew where the bodies were buried, and he was capable of being absolutely ruthless, doing whatever it took to win his way. Moreover, in contrast to Obama, LBJ had a landslide victory—the largest plurality in U.S. history. He had the wind at his back. Even then, it took him 19 months to achieve his goal—19 months on top of the 18 months that JFK already had invested in the campaign.
Johnson made just one big mistake: he gave doctors and hospitals the power to charge Medicare whatever they wished.
In Part 2 of this post I will describe how this blunder turned healthcare into a multi-billion dollar industry run, not by physicians, but by corporations. I’ll also explain why our for-profit healthcare industry would like to see Obama rush to roll out universal coverage at any cost—without putting the regulations in place that will be needed to constrain corporate greed and guarantee safe, affordable care. Obama cannot afford to repeat LBJ’s error. He must contain health care spending while designing a program that rewards the most effective care. Otherwise, corporate interests will complete their takeover of American medici
ne and patients’ interests will be forgotten. Finally, in the second part of this post, I will explain why, in contrast to the Clintons, this administration has a much larger political window. This recession will not end in 2010.
I get nervous when I read about reforming healthcare quickly.
Just to mention two concerns: lack of primary care and business practices of private health insurers.
Primary care – It seems to me that in Mass’ modest reform not everybody who was newly covered was able to access care. This problem affects all states.
At last notice some legislation to fund community health centers and expand medical education is still locked up in Congress. So what will haste accomplish, millions of people paying premiums who can’t see a doctor?
Private health insurance (phi) – The role that phi will play in health reform has not been clearly publicly discussed. Oh yes there have been some references to controlling or eliminating medical underwriting, but there are other substantive problems with the business practices of private insurers that need to be hashed out before a cent is spent on expansion. The practices I refer to have been clearly explained by the Healtcare Association of New York State and can be found as part of the organization’s state legislative agenda for 2008 at http://www.hanys.org.
There are many other aspects of reform which have not yet been adequately discussed.
Let’s get a firm basis for reform or the problems will get worse.
It simply and absolutely means getting the ‘for profit so-called health insurance companies out of the Healthcare business. It means adopt, now, a single-payer system such as carefully outlined in H.R. 676. It means doing it now. Not in four more years.
Get rael! People are dying.
That’s real.
It is good that you are revisting the genesis of Medicare and lessons learned.
While Medicare was a success for a while it has been corrupted in many ways as we all know. That is why I personally resist the “Medicare for all drumbeat also”
My latest message is that by adding all uninsured and underinsured into current Medicare that would be the equivalent to the government providing a bad loan to a person with limited financial means in 2008 to buy a gas guzzling automobile.
We would NOT be doing them or our nation any favor.
Helping people get enrolled into a fundamentally and conceptually broken system will not carry the day.
I hope we can stop what may be a steamroller?
Dr. Rick Lippin
Southampton,Pa
As comprehensive as this is, Maggie – first rate, as usual, it doesn’t address the most undervalued, highest ROI resource.
As you are one of the very few experts who ever even entertained the notion of nursing as a legitimate health reform stakeholder, it’s that continued invisibility that finally drove me to stop blogging.
I’m waving the white flag. Conventional thinking wins, and I only hope that the ghost technicians who replace professional nurses don’t cause even more preventable patient harm and deaths.
“I told you so” is bitter fare, and watching this crisis of opportunity freeze nursing out is the bookend to a career that has been devastating to me in every conceivable way.
As I appreciate and am grateful for your insight and analysis, I can’t torment myself with trying to pry open the window of opportunity for proportional representation any longer.
Thank you all for your comments. I’ll get back to everyone tomorrow, but right now, I want to respond to Annie because she is clearly feeling discouraged.
Annie–
I’ve put together a working group on Medicare Reform made up of 10 of the most visible doctors and public health experts in the country.
They all realize how important nurses are to healthcare and healthcare reform.
I should have put a nurse on the panel–but at the time, the only people I knew were the California Nurses Association, and while they have done some good things, they have their own political agenda.
Nevertheless, I plan to highlight nurse practioners in our report.
I think that Medicare should provide incentives for academic medical cdenters to train doctors and nurses together in some areas. Healthcare is a “team sport.” Docs need to think of nurses as part of the team.
And if we want more primary care physicians, geriatricians and palliative care specialists we need more specially trained nurses working with them. Medicare will need to pay those nurses more.
Nurses are key to creating medical homes; this is not something doctors can do alone.
We also need more geriatric nurses and palliative care nurses.
Trust me, I won’t give up on this issue, or forget it.
Please keep reading the blog, commenting and reminding me.
I akso would appreciate it if you if could give me a “head’s up” on any good stories that you see in the news or elsewhere about nursing.
Please comment here, or e-mail me at Mahar@tcf.org
Joan C–
Thanks for commenting.
I agree with you on all counts.
We need community health centers. And today, people with insurace still cannot get an appointment with a primary care doctor.
Thanks for the link to
http://www.hanys.org.
Finally, you are absolutely right: we need to have a much more substantive discussion about regulating private insurers,putting alid on prices . . .
These issues are complicated, and the lobbyists representing the for-profit industry dearly hope that we will just skip ahead, without trying to work these things out.
More than health care reform this nation needs to improve the quality of its food supply and the quality of nutrition instruction. Doing these two things would likely reduce the burden of chronic disease to affordable levels.
There’s considerable grass roots interest in the former and some good activity regarding the latter. Unfortunately, the major impediment to providing Americans with sound dietary advice is the federal government’s Dietary Guidelines for Americans.
The government began issuing dietary advice in 1977. The first publication was called Dietary Goals for the United States. Three years later, in 1980, the first Dietary Guidelines for Americans was issued. Both publications contained four major mistakes that have yet to be corrected.
The first is the idea that saturated fat causes heart disease. This doctrine has gained world-wide acceptance despite research demonstrating quite the opposite. Google “saturated fats truth benefits” to clear up this misconception.
The second idea is that a low-fat diet is required for weight control. Again, research does not support this doctrine. Google “Jeff S. Volek” or “Richard D. Fineman Nutrition & Metabolism” or “Stephen D. Phinney.”
The third mistake is the failure to link excessive sugar consumption to clogged arteries. Google “Peter Havel fructose” to access recent findings.
The fourth error is failure to link excessive omega 6 vegetable oil consumption with cancers and cognitive and emotional disorders. Google “omega 6 oils hazards” to access research and comment.
It’s hard the say whether Americans would have been healthier had the Government refrained from providing dietary advice. I do know that other countries have patterned their own dietary guidelines after ours. With such widespread consensus it may take a miracle to turn things around. Or it could take a few courageous, well informed politicians. I’m working on that.
MM is impressive, in wit, in depth of research, in quality of response-panel. I agree that a very major MD+RN+Social worker+Health Economist input, charged with lowering waste in the current non-system, is a key element. In many medical schools (cf Arnold Relman, “Second Opinion”) and schools of Public Health, Nursing, Biomedical Engineering (cf Columbia), the skills, and will, are here, or rapidly developing. (Even the AMA is a very different place than the Annis AMA; past presidents Public Health and Med School Associate Dean.)
While we pray that the Professionals will step up to their tasks (the students are there ahead of us!), the Vehicle must make for-profit disappear; HR676, undoubtedly amended, should be our first best hope.
Dick Pierson
To Dave Cox
HR 676 has not been carefully outlined.
It addresses issues of importance to physicians while suggesting general remedies (such as globa budgets)for problems that affect the other health care providers.
If 676 were enacted tomorrow we would still have to develop effective ways of solving the problems of our system. I’m not prepared to hand every decision over to a remote health policy board.
If you want to see a piece of single payer legislation where the drafters did their homework, I recommend
California Bill SB840 which was passed by the legislature twice only to be vetoed by the Governor. It includes input by all stakeholders, even consumers into the implementation and operation of the system.
The Covert Rationing Blog has been mentioned here before, and this Dr. Rich character writing about himself in the third person is quite effective. He really does have a way of hitting the nail on the head with his own style. Check out this latest post:
http://covertrationingblog.com/general-rationing-issues/being-thankful-for-the-uninsured#comments
There is something in this for all healthcare believers:
What to cover?
The ER provides all the care the uninsured need
Let people pay on their own, and they will magically get effective efficient healthcare
Bottom line is we are in deep crap with our current healthcare non-system, and we better figure out what works well and how to fairly distribute only that!
Dave Cox, Rick, David, Dick, NG and Joan-
Thanks for the comments
Dave Cox–
As Joan ponts out, HR 676 still doesn’t solve the problem of delivering Effective care to all Americans.
The other problem is that 85% of all Americans have employer-based insurance and do not want to give it up for an unknown government program–so we’re not going to see single-payer anytime soon.
For more on single-payer, see my reply to Dick below.
Rick–
Yes, Medicare has been corrupted. It now covers too many things that don’t help us–and may hurt us.
Meanwhile it over pays for overly aggressive intensive treatments, while underpaying for things like Palliative care and geriatric care.
We need to reform Medicare–beginning next year–and make that a pilot project for national health reform.
David– you are right that
more “healthcare” is not all that we need (or even what we need most for better health.
What we eat, the environment, and poverty are all major factors influencing our health, and we should pay more attention to all three.
I’m not an expert on nutrition, so I’ll defer to you on specific points.
Dick– Thanks for the compliments.
I have nothing against single-payer. In fact, I agree with Obama, if one were starting from scratch today, it would make a lot of sense.
But we’re not–and that 85% of the population that has an employer paying for much or all of its insurance doesn’t want to give that up. (Fifteen percent of “better paid workers”–earning over $70,000 if memory serves–actually have an employer who pays 100% of their insurance premium. Others in that group have employers who, on average pay roughly 60 percent. )
But single-payer requires that Everyone join the plan. (Otherwise healthier, more affluent employees would stick with the plans they have and poorer, sicker people would sign up for the single-payer public sector plan, making it unaffordable for everyone.
Joan C– You are right
Single-payer doesn’t solve the most difficult problems–i.e. the hard choices about what should be covered. IF we had single-payer and covered everything that everyone thinks they want, it would be totally unaffordable.
Moreover,we know that lower spending and higher quality ,more effective care go hand in hand. So to lift quality, we have to figure out how to contain costs.
NG– Thanks for the link to http://covertrationingblog.com/general-rationing-issues/being-thankful-for-the-uninsured#comments
You are right; it is very funny. And to the point.
I think Obama has to utilize his political capital immediately to reform the health care industry. I wrote about it today in the Huffington Post – http://www.huffingtonpost.com/jeffrey-m-sandman/dive-right-into-health-ca_b_147691.html
This is a great discussion.
I work with Dr. Denis Cortese in the Mayo Clinic Health Policy Center. For the past two years, we have been bringing together leaders from all sectors of health care including patients and patient advocates, providers, insurers, large and small employers, medical industry and pharma, government, and academia. Together, these more than 2,000 leaders arrived at consensus on four priorities for health care reform: health insurance for all, payment reform, creating value and coordination of care.
It is important that we work on all of these things together — they cannot be successful individually. To create value, we must have better safety, better service and better outcomes. When there is demonstrated value, payment should reward it. We should not be paying for poor value. And part of the way to get good value is to coordinate care through care teams — often led by primary care providers — and facilitated by robust and interoperable health IT.
This is not a simple issue; there is no one solution. But there are many, many good ideas about how to get it done.
I would invite you to see more about these priorities and recommended action steps at our Web site http://www.mayoclinic.org/healthpolicycenter/recommendations.html .
Jane:
Thanks very much for youf comment,\. I agree–particuarly on the point that there are “many many ways to get this [equitable healthcare reform] done.”
The more I have learned about healthcare, the more I have come to realize that a successful provider program is based on the culture of the organization.
We need to reward succesful cultures–and let other organizations know what these organizations are doing right.
At the same time, other organizations will have to Adapt what they learn to their own culture– we are not talking about cloning Toyota factories.