Federal Reform Bill Is a Start
By Jan Malcolm
No matter which side of the political aisle you’re on or where you land on the single-payer-to-free-market continuum, all can agree that 2010 has been a milestone year in the complex world of health policy.
The Patient Protection and Affordable Care Act signed into law by President Barack Obama in March is as significant today as the introduction of Medicare was in 1965. I hope both lawmakers and the public will see this as the beginning, not the end, of an evolutionary series of reforms. Those of us in the trenches are all too aware that much more is needed to make universal access to high-quality, affordable care a sustainable reality in our country.
Although it is just a start, the new law represents a huge step in the right direction for millions of Americans caught in the widening gaps within our medical care system. In fact, it offers all of us much greater assurance that our future health needs will be met. By beginning to fill the holes in our patchwork-quilt coverage system, and by emphasizing prevention and innovation in the new care delivery models and financial incentives that support them, the legislation projects better health outcomes and significant budget savings over the next 10 years. For higher-risk populations such as those we serve at Courage Center, these changes can’t come soon enough.
The law will be implemented over the next several years, and there is room for skepticism about whether the demonstration and pilot projects included in it will grow to scale fast enough to assist much with the ongoing crisis of health care cost escalation. It’s up to those of us who know how far short our current system falls to make sure that reform succeeds and that we learn and adjust as we go forward.
As we do, let’s make sure we keep our eyes on the prize. If we are going to really heal the health care and insurance systems, reform has to fundamentally be about health—not just about how we pay for medical interventions. The health care delivery system and the public health system are inextricably intertwined. And the more we learn about what really produces health, the more we realize that other public policy areas such as education, transportation, and economic development have huge effects on health and on health care costs.
The big question is this: How much health are we producing for the population? If the individual is the unit of analysis rather than the entire community, the claim that our system is the best in the world understandably has staunch defenders. Most would agree that our system certainly has the capability to produce phenomenal results for individual patients. But on a population level, we have much less to brag about. In 2000, the World Health Organization ranked the U.S. health care system No. 1 in terms of cost (16 percent of gross national product), 37th in overall performance, and 72nd in the overall level of health among 191 member nations included in the study. More recent analyses have found similar results. Ours is a system fully capable of greatness; but we aren’t getting the bang for the buck that is needed in today’s global economy. We need to do a better job of deploying our considerable resources to actually improve health and to reward value, not just generate a volume of health services.
The Importance of Public Health
The new reform law, like the Minnesota health care reform bill that was signed into law in 2008, makes a major commitment to public health, with increased funding for health department activities and broad community-based prevention strategies. The attention is welcome—and badly needed. But we have a lot of work to do to help the public understand the meaning and importance of public health. Various surveys have repeatedly shown that the majority of people don’t have a clear picture of what the public health system is or does, and most are pretty sure they never have needed its services. Most people think public health means publicly subsidized health care through Medical Assistance or federally subsidized clinics. These are indeed critical to public health; but very few people realize that public health is part of our daily lives—every one of us relies on it every day.
What difference does public health make? In the 20th century, public health efforts focused on rampant infectious diseases, urban squalor, unsafe housing and worksites, inadequate sanitation, poor hygiene, and family planning. The dramatic reduction in tobacco use stands as a relatively recent and ongoing public health victory. During the past century, such public health initiatives have been responsible for 25 of the 30 years gained in average life spans in the United States. To modify the status quo, every one of them required solid data, political will, courage, and public investment.
Today, improved public health is essential to making health care costs sustainable in the future. Public health approaches address the factors that both undermine health and protect it. Public health leaders deeply understand the impact education and economic opportunity have on health. It’s common knowledge by now that healthy kids learn better and that educated kids grow into healthier adults. We also know that many other industrialized countries have lower infant mortality rates than the United States and that our relative ranking on this measure has fallen considerably over the last few decades, despite the explosion in spending on health care. What is less well-known is that worldwide, one factor that has one of the most profound positive effects on infant mortality is maternal income security. Want healthy infants? Have their mothers live in safe environments where their basic needs can be met.
Improved public health requires that we pay closer attention to conditions within the community. Yes, individuals should take more responsibility for their health choices, but those choices aren’t made in a vacuum. We as a society must do more to establish conditions in which all people can make healthier choices. We should evaluate public polices outside the medical care arena for their impact on public health. These include housing policy, transportation policy, education policy, and agriculture policy. Some researchers argue that we could make a sizeable dent in our national obesity crisis if the price of corn was not artificially subsidized and if high-fructose corn syrup was not so prevalent in our diets. Are we ready to take on this challenge?
Solving Problems Together
In public health, there is a parable about this interdependence. It goes like this: Those of us who represent the “system”—all of us who can heal, comfort, pay, predict, build and “manage” aspects of health care delivery—stand on the bank of a river. Individuals begin to appear from around the bend—floating, treading water, swimming, struggling, and drowning. We go into the river and save those we can; but they appear in greater numbers at a brisker pace. We begin focusing on faster, smarter, more high-tech, and increasingly expensive solutions to fish these folks out of the water. But it isn’t until much later that any of the rescuers ask, “What are these folks doing in the river in the first place?” Eventually, some inquisitive soul goes up river and discovers a broken bridge.
In the complex world of health and health care, fixing the obvious—going up river—is no less difficult than fishing people out of the water. In today’s system, the incentives and structures of delivery lead us to put more than 95 percent of our “health” dollars into attempts to cure or cope with our failure to prevent. The vast majority of medical spending (75 percent to 80 percent) goes to treat chronic conditions, some of which can be prevented altogether and almost all of which can at least be ameliorated with primary and secondary prevention. Prevention is more than individuals doing battle singlehandedly against the addictive nature of nicotine (dispensed in a carcinogenic applicator marketed as irresistible) or walking away from cheap, readily available, high-calorie, engineered foods.
Improving individual and population health and making more efficient use of our resources requires our willingness as a society to take a long-term view. This is no quick fix. It will take time and investment. It will require a collective realization that we all need to take more responsibility for our health choices as individuals and for the conditions in our communities that so powerfully affect those choices and outcomes. We need to act on our knowledge that prevention at multiple levels and the earliest possible evidence-based interventions will mean less suffering and a better quality of life for everyone. It may take a biennium or two—or perhaps a generation—for this to occur. But a robust commitment to a true health system will ultimately mean less money spent on preventable illnesses and secondary complications.
Every day at Courage Center, we see that with early intervention through excellent therapies, a balanced, lifetime regimen of adaptive fitness, and full participation in the community, our clients with significant disabilities experience much higher levels of health and independence. Medical problems secondary to their disabilities and provoked by isolation and inactivity such as diabetes, pneumonia, skin problems, and depression are minimized or prevented. The result is a healthier individual with a sense of purpose at less cost to private health plans, government insurers, and society as a whole. This is an example of the promise of health care reform.
Jan Malcolm is chief executive officer of Courage Center. She served as Minnesota’s Commissioner of Health from 1999 to 2003.