Health Care Reform? Not Yet

What should health care reform be about? Think health care, not health insurance. Oh, and access to good care would be nice, too, especially in rural communities.

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I’m frustrated, but not surprised, by the way the President and House leadership have approached health care reform. Nothing in the current discussion offers any promise for better days for any of us, but particularly for those living in rural America. 

The health care debate should be about health care not health insurance, about how to properly balance the public and private sectors, not about the government running or not running health care.

We should be talking about how to ensure that adequate services are available to rural America, about how to streamline the systems and processes and thereby lower cost and improve quality, not just how to “cut costs” (which usually means more regulation, more complexity and more hassles for providers, particularly doctors).

And the discussion in Congress should be about how to provide an adequate health care workforce everywhere, including rural areas.  

The organization and delivery of American healthcare is a mess.  I hear people say, “We have the world’s finest health care system,” but there is no system. Instead, there are a mind-numbing number of independent (although somewhat interrelated) actors — insurance companies, third party administrators, hospitals, physicians and other providers, pharmaceutical companies, equipment manufacturers, data processing organizations, public health departments. And they are all operating without any sort of coordination, oversight or direction. 

I believe that the President has made two serious mistakes in this process. He has let the debate turn into a partisan political fight, and he has started identifying villains.  Both of these are normal reactions for a political figure dealing with a complicated and difficult issue, but they are both counterproductive in the extreme.

Partisan Politics 

As the Blue Dog Democrats pointed out in their July 9, 2009 letter to House Speaker Nancy Pelosi, America’s health care problems cannot be solved in a partisan manner, but must be addressed in a bipartisan way in order to achieve meaningful reform. Neither political party can fix it; we need middle-of-the-road solutions. This fact was recognized by the U.S. Senate Finance Committee, chaired by Senator Max Baucus of Montana.  On November 12, 2008 his committee issued an 98-page report entitled Call to Action: Health Reform 2009.  

The report was the result of nine hearings and a day-long summit to explore “in greater depth the problems plaguing our health system.”  The report identified just about every problem that anyone could think of related to American health care and offered common-sense solutions. Throughout the report it was consistently stated that this was not a plan, not a piece of legislation, but a working document to be used as a starting point for meaningful reform.   

Shawn Poynter/The Daily Yonder
As deal-making continued in Congress on health care legislation, President Obama traveled to rural Virginia (and Tennessee) to pitch his proposals.

The administration should have taken Call to Action and pushed it hard from day one. Instead President Obama stood on the sidelines and let the House leadership and the Senate Health, Education, Labor  and Pensions Committee start from scratch with draft legislation. Meanwhile, the Senate Finance Committee’s bill has not been finalized. Senator Baucus and the ranking Republican on the Committee, Senator Charles Grassley from Iowa, are committed to drafting a bill that can garner bipartisan support. A bipartisan bill takes patience, dialogue, and give and take that are at times tedious and painful but well worth the effort. 

We can speculate that losing former South Dakota Senator Tom Daschle as the Obama Administration’s point man on health care reform was such a blow to the President that he wasn’t sure where to turn for leadership.  And now because Senator Baucus is more bipartisan than many of his colleagues, his efforts seemed to have been ignored by the Democratic leadership and the President.  

Identifying Villains

I have come to believe that in order to find health care solutions we must take the position that there are “no villains.”  I first heard this phrase used in the health care debate in the early ’90s by UCLA public health professor Paul Torrens, MD. In a major address at the University of Louisville, Torrens said,

“Bad people didn’t create this situation on purpose…..We are victims of our successes; success in building hospitals, in building more medical schools to train more doctors, in creating an insurance industry that covers 80% or so of the population, and in leading the world in technology & pharmaceutical development.”

Paul went on to point out that all these developments were undertaken by people and organizations without a national policy on what kind of a health system America wanted or needed.  Ever since hearing this, I have held to the belief that it is counterproductive to blame our current mess on any one part of the system. As President Clinton learned in dealing with the health insurance industry, once someone is labeled a villain he will fight back.  

The more that President Obama criticizes “special interests,” talks about “keeping insurance companies honest,” or accuses doctors of doing unnecessary procedures just for the money, the less likely it is that any of these parties will be willing to work together to find reasonable solutions.

Comprehensive Reform

True reform isn’t just about insurance or having a public option. I agree with a colleague who sent me this email over the weekend: 

Paperwork is a bigger concern of family doctors than specialists
Creating the public option, without “solidifying” the base upon which this public option is built (i.e. moving from a paper-based to an electronic system, making sure primary care providers are available, reforming reimbursement, and holding patients accountable to some degree for their health and wellness) is, in my opinion, another governmental program that is designed to fail — fail the patients, the providers, and our economy.   

Meaningful reform must be comprehensive. For reform to be comprehensive it must address access, affordability, accountability and personal responsibility.  Not addressing all four leaves a flawed plan. Currently the national debate mostly emphasizes affordability and hardly mentions access, accountability or personal responsibility.  The following is a quick look at how to accomplish all four of these objectives.

Access  We need for everyone to have a medical home.  However, it would take a ten-year effort to build the primary care provider workforce to do this.  While I believe passionately that such an effort needs to be undertaken, I think that we can accomplish much with universal coverage and better information.  If patient data is available (either on a card like a bank card, or via a secure web site) and if the visit is paid for, the currently uninsured can seek care anywhere — from a doctor, an urgent care center, or a Kroger kiosk.  Any of these choices is better than the current costly abuse of emergency rooms. 

Affordability We need to make a national commitment to leave paper behind and build a truly functional electronic system.  As we do that we can simplify the payment process, which will result in a decrease of the share of the health care dollar going to administration and to unnecessary and duplicate tests and procedures.  Without that, “cost-cutting” will continue to result in the counterproductive micro-managing of reimbursements.

Accountability With better and more easily obtainable information we can provide meaningful feedback to providers. We will be able to measure and then reward quality care.   

Personal Responsibility Changing the behavior of Americans will take a massive effort.  It will take education, worksite wellness programs and establishment of school health and fitness programs.  We need incentives at all levels to encourage healthy behaviors. We also need some sort of disincentives that require those who practice unhealthy lifestyles to pay more for their care. 

Having spent a significant amount of time on health care reform during my career, I’m pained to say that we seem to be on the verge of blowing another opportunity for significant and lasting change that will really be accessible, affordable, accountable and built on personal responsibility. It seems ironic to me that these four principles, which most rural people understand, appear to overwhelm the best and brightest in Washington.

We may or may not pass reform — at his point I’m not sure which I’m pulling for.  As bad off as we are and as unsustainable as our current “system” is, I’m afraid that the reform proposals being considered will make it worse, particularly for rural Americans.

Robert Slaton is the former Commissioner of Health in the Commonwealth of Kentucky and is now chair of the Kentucky Chamber of Commerce’s health care committee

 

 

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