ISSUE IN-DEPTH: HEALTH CARE REFORM: We can’t afford to wait to fix this broken system

The depth of the nation’s financial crisis seems to argue that major reform efforts on a host of long-delayed critical issues should be put off yet again. But getting started on fixing the nation’s health care financing system is more important than ever.

Indeed, this country’s expensive and inefficient health care delivery system is linked to many of the financial problems facing U.S. manufacturers, most notably American automakers. While many of the Big Three’s problems are self-inflicted, even their critics acknowledge that Detroit’s obligation to provide health care coverage to its workers and retirees has made them less competitive in the world market. The long-term survival of the industry —- and much of the nation’s manufacturing sector —- depends on finding a solution that takes some of the burden of health care costs off not just employers but their workers and the people who buy American goods and services.

A major health care initiative “has to be intimately woven into our overall economic recovery plan,” President-elect Barack Obama said last week, adding: “It’s not something that we can put off because we are in an emergency. This is part of the emergency.”

The drive to change the troubled system is also being pushed by angry health care consumers. Americans are fed up with a system that requires so much out-of-pocket spending and whose benefits are so inconsistent. Numerous surveys show that many American families, even those with insurance, are a step away from bankruptcy because they would not be able to afford the cost of care due to a serious injury or illness. That helps explain why nearly two-thirds of Americans believe comprehensive health care reform should proceed despite the financial meltdown.

The United States spends more per capita on health care than any country: $2.3 trillion yearly. That represents an astounding 16 percent of our gross domestic product, more than any other sector. Yet by numerous measures, our country lags far behind other nations in overall health. We rank 29th in infant mortality, 14th in life expectancy and 19th of 19 industrialized nations in preventable deaths.

Of course, politicians still like to boast we have the finest health care in the world. That might be true for those wealthy enough to secure the care they need from specialists at high-tech medical centers around the country, but it certainly isn’t so for most Americans. The latest evidence of a dysfunctional system came last month in a survey of chronically ill patients. Alarmingly, nearly half of chronically ill Americans with health insurance said they did not get the care they need to stay healthy because they could not afford it.

Given such dissatisfaction, reform should be easy; but don’t count on it. The standoff of the last 30 years —- pitting a free-market approach against more regulation and government subsidies —- remains firmly in place, even with Obama’s election and a more dominant Democratic Congress.

Powerful interest groups with sometimes competing goals —- from insurance companies and pharmaceutical firms to family-practice physicians and medical specialists —- also remain heavily vested in the current system and will try to scuttle reform, just as they did in 1993.

The key goal of reform this time will be to pay for results. For physicians, that will mean managing chronic illness better and adopting electronic medical records. For insurers, it will require financial incentives that reward success in patient management rather than procedures performed. And for patients, it will mean accepting the fact that expensive, unproven therapies will not be covered. (Science and research have already given doctors a good idea of what treatments work best and at what price.)

Dr. Reed Tuckson, vice president of UnitedHealth Group in Minneapolis, offers this example: Health insurers now spend $450 billion annually treating cardiovascular diseases. Most of that is spent in specialty care bypassing clogged arteries in surgery, placing stents in reopened blood vessels and providing costly follow-up tests and medications.

Instead, resources should be shifted to reward primary-care physicians for helping patients to quit smoking and control blood sugar levels, hypertension and cholesterol.

Such reforms can be embraced by Democrats and Republicans, but they don’t address the biggest problem: How to finance delivery and financing of health care.

Supporters of a universal health insurance system financed by the federal government make a good case that it is the most efficient and comprehensive approach toward ensuring health care for all. They argue for a Medicare-like system, with better incentives for prevention, available to all Americans, not just the elderly.

Such a system would clearly be superior to the fractured, expensive, administration-heavy system we have today; but if the country is not yet ready to take such a leap for everyone, there may be a middle ground.

Just as Medicare guarantees that the nation’s elderly have access to health care regardless of income, we should now extend a similar guarantee to the nation’s children. The State Children’s Health Insurance Plan —- a 1997 program that makes affordable and comprehensive insurance available for children in families not covered by private plans —- could become the basis of a broader program that removes income from the equation.

Like Medicare, it would pool the nation’s children under one program and relieve employers and families of the burden of financing most of the costs themselves. It could be paid for through a combination of payroll taxes and, like Medicare, premiums for higher levels of coverage. It would give every child access to immunizations, preventive care and services that would keep them healthy and control costs. If it works well, the system could be extended to adults.

Such an approach may take longer to carry out, but it would in time answer questions that so many politicians have avoided for so long:

Do Americans have a right to health care, and if so, how much are we willing to pay for it?

—- Mike King, for the editorial board

 CHARLES W. JONES / Staff
DESPITE BAD ECONOMY, SUPPORT FOR MAJOR REFORM
The Kaiser Family Foundation asked 1,217 registered voters nationwide in October how they would answer the following question: 
> "Which comes close to describing your own views: Given the economic challenges facing the country ...
62 percent said it is "more important than ever to take on health care reform."
34 percent said "we can not afford to take on health care reform right now."
4 percent said they did not know or declined to answer.

AMERICA: NOT THE PLACE TO BE CHRONICALLY ILL
In eight countries, adult patients with one or more chronic illnesses —- such as diabetes, heart disease, arthritis, asthma and emphysema —- were surveyed to gauge their impressions of cost, access to care and how they were treated in their nation's health care system. The results showed that Americans are much more likely to have significant out-of-pocket costs and more likely to rely on the emergency room for care. Americans with chronic illnesses were also much more likely to be able to see a specialist quickly compared to chronically ill patients in other countries.

Costs
Percentage of patients who had out-of-pocket medical expenses of more than $1,000 in the past year.

Australia: 25%
Canada: 20%
France: 5%
Germany: 13%
Netherlands: 8%
New Zealand: 14%
United Kingdom: 4%
United States: 41%

Primary-care access
Percentage of patients who found it very difficult or somewhat difficult to get care at nights and on weekends without having to go to an emergency room.

Australia: 62%
Canada: 56%
France: 56%
Germany: 36%
Netherlands: 30%
New Zealand: 39%
United Kingdom: 44%
United States: 60%

Specialty-care access
Percentage of patients whose wait for an appointment to see a specialist was less than four weeks.

Australia: 45%
Canada: 40%
France: 55%
Germany: 68%
Netherlands: 69%
New Zealand: 45%
United Kingdom: 42%
United States: 74%

How Americans feel about their health care 
Americans without health insurance, especially those with a chronic condition, are much more likely to want the nation's health care system overhauled. But even insured Americans with chronic illnesses report dissatisfaction with coordination, efficiency and access to care.

> Percentage of patients who think system needs to be completely rebuilt
Uninsured: 46%
Insured: 27%

> Percentage of patients who had time wasted or received inefficient care
Uninsured: 54%
Insured: 43%

> Percentage of patients who waited more than six days and never got an appointment
Uninsured: 37%
Insured: 18%

> Percentage of patients who had a problem with access to a doctor because of cost
Uninsured: 82%
Insured: 43%

Check our sources
Data for these charts came from the Commonwealth Fund International Health Policy Survey of Sicker Adults, 2008. The survey is available online through the policy journal Health Affairs. Note: Some content on the Health Affairs site is available through subscription only.
http://content.healthaffairs.org/
Health policy information from The Commonwealth Fund is available at: http://www.commonwealthfund.org/
Other useful sources on the issue of health care reform can be found through the Kaiser Family Foundation, http://www.kff.org/ and the Alliance for Health Reform: http://www.allhealth.org/