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How to Achieve True Health Care Reform

(Peter Beilenson, MD, MPH) -- As the 2008 presidential election approaches, many policy wonks and advocates are pontificating on how best to achieve true health care reform in the United States.  So here are some of my thoughts on the issue!

Although organizations with which I have been associated have primarily been advocating universal health coverage—and I have become known for supporting the same goal for over a decade—I have come to the conclusion that campaigning predominantly for health care for all is not the most effective route to political success in reforming the American health care system.  Now, don't get me wrong—I still believe, passionately, that access to health care is a fundamental human right---I just think there may be a more direct way to reach this goal.  What brought me to this fundamental change in approach is the following fact. Despite widespread, bi-partisan support for universal health coverage, as evidenced by poll after poll over the past decade, we actually have almost 33% more uninsured Americans today than we did at the time of the Clinton Administration's failed health care reform effort of 1993 (47 million vs. 36 million, according to the U.S. Census Bureau).  If the public truly felt strongly about this issue, certainly politicians would have responded by now.  Yet, not only  have there been no serious federal proposals to reduce the number of the uninsured—in fact, the current Administration has done everything in its power to make it harder to obtain health coverage for the most vulnerable among us, with very little public outcry.  

The problem, paradoxically, is simply that too few Americans (less than a fifth of us) currently lack insurance.  So, although many more are worried about the potential of losing their coverage (i.e. that their employer may drop coverage, or they lose their job), not enough are directly affected by lack of health coverage to overcome the natural human fear of change.  In other words, the devil they know (the current health care system with all its many faults) is better than the one they don't (some type of untried health care reform).  Thus, the continued attempt to achieve universal health coverage as the primary goal of health care reformists is doomed to continued failure.  

I believe that the way to true health care reform is to re-frame the issue to one that affects virtually all Americans—addressing runaway health care costs.  There are several major reforms that would save significant amounts of money and dramatically increase the quality of care given:  a) promoting health information technology—which will dramatically decrease duplication of tests and procedures; b) value-based purchasing—a new idea where there would be economic incentives to purchase medications, screenings, or procedures that are less costly but more effective than other commonly available alternatives; c) strong efforts to address the obesity epidemic and tobacco addiction, which contribute to much of the burden of preventable conditions; d) changing the payment structure of Medicare to both allow for negotiated prescription drug pricing and to pay physicians for episodes of care rather than fee-for-service; and e)  probably the most important source of savings:  affordable health coverage for all!  The Commonwealth Fund, one of the most respected health care-related foundations in the country estimates that these and a handful of additional reforms could save approximately $1.5 trillion (with a "t") over the next ten years.  These savings would allow for a dramatic slowing of the expected inexorable rise in health care costs over that period.  Tying these reforms together as a cost-saving package would potentially accomplish what hasn't truly happened to date: the development of a strong, loud public outcry for health care reform, with universal health coverage the most important byproduct.