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Healing the U.S. health care system: There's no easy cure
By Judith VandeWater Of the Post-Dispatch
10/17/2004
Patients and doctors, business owners and working people, lawmakers and economists agree: The U.S. health care system's problems are so big, so tangled, that it's hard to know what to fix first. Tackle one issue, and another gains potency.
Technology, the great driver of health care costs, is also the driver of hope and cures. Escalating costs, in turn, have weakened the nation's work-based health system. Health insurance is out of reach for 45 million Americans, and experts predict their ranks will swell by 2 million a year for the foreseeable future.
"We have led the world in the medicine of the future. We are the major producers of better health," said Dr. William Peck, director of the Center for Health Policy at Washington University. "On the other hand, we are carrying the yoke of high and rising costs of health care and the uninsured."
Plenty of reforms are being floated in Congress, but no initiative has broad support. The continuing partisan rancor over the new Medicare drug benefit underscores how little common ground politicians have found.
Fed up with waiting on Washington, some states and private coalitions are chipping away at the issues. Among them:
Fifty Fortune 500 companies are sponsoring an initiative that will make coverage available to 4 million part-time workers and others who are without insurance.
Gov. Rod Blagojevich has launched a plan that will help Illinois residents buy cheaper drugs from Canada, Ireland and the United Kingdom through an online clearinghouse.
The National Coalition on Health Care is calling for universal coverage, insurance price regulation and national standards for medical care. Its member groups - big businesses, unions, faith organizations, pension and health funds, insurers and patient-rights groups - represent 150 million Americans.
If history is a guide, the reformers face formidable obstacles.
The $1.6 trillion a year Americans spend on health care gives entrenched interest groups, including doctors, pharmaceutical companies, Wall Street investors, large insurers and big hospital companies, powerful incentives to maintain the status quo.
Three presidents, Harry Truman, Richard Nixon and Bill Clinton, each tried and failed to achieve universal coverage. The shock-and-awe offensive that decimated the Clinton plan in the 1990s still chills attempts at imposing insurance mandates.
Proponents of universal health insurance contend that mandates and public subsidies are needed to achieve broad coverage in our hybrid system, which is built on government and private insurance. Opinion surveys show many business leaders oppose mandates.
Political infighting is wasting valuable time, said David P. Seifert, former chief executive of St. Anthony's Medical Center and a principal with the Alexander-Seifert Consulting Group in St. Louis.
"If decisions are put off until the insatiable appetite of the baby boomer generation has turned to consuming health care, it will be too late to solve the cost problem," Seifert said.
Neither political party supports compulsory health insurance this time around.
Sen. John Kerry, the Democratic candidate for president, favors a stronger federal role. Under his proposal, the government would assume most of the financial risk of catastrophic costs, in turn lowering insurance premiums. It also would create new insurance plans for small businesses, for Americans ages 55 to 65 and the unemployed.
President George W. Bush, the Republican candidate, would allow the free market to serve up solutions. Bush-backed policies and proposals include tax-advantaged health savings accounts and association-based health plans for small businesses. One initiative, consumer driven health care, is gaining buzz in a business community desperate to control runaway costs. Typically, these high-deductible policies are offered with either a health reimbursement account or health-savings account.
Consumer-driven plans are the "flavor of the moment," said Humphrey Taylor, chairman of the Harris Poll, which tracks public opinion on health care. He said the danger is that the plans will attract young, healthy workers. That would leave older and sicker people in insurance pools that concentrate and superheat costs.
In Western nations, health care financing is based on the healthy helping pay for the sick and the rich subsidizing services for the poor. That social construct is fraying in the United States.
Increasingly, Americans expect to take as much out of a health plan as they put in, Taylor said. They are not concerned with creating a pool of money to pay for the small number of very sick patients.
"We have a great health care system for people who are healthy and a not so great one for people who are seriously sick," Taylor said.
A Harris poll last fall found most Americans did not expect the system to change for the better.
Those who believed that unemployed and poor people should get the same amount and quality of medical services as taxpayers with good jobs fell to 75 percent, a drop of 9 points in a little over a decade.
But the hottest issue for Americans is not insuring the uninsured, Taylor said. It is the cost of prescriptions.
Drugs account for only 11 percent of health spending, but the cost is a kitchen table topic. Bigger co-payments and deductibles have heightened anger over rising prescription prices.
"Hospital costs are rising faster, but the insured are insulated from that," he said.
Celinda Lake, a Democratic strategist and pollster, said voters rank the rising costs as the most pressing health care issue.
The middle class is in a financial bind, she said. Workers worry that jobs being outsourced overseas are being replaced with jobs that don't provide health insurance.
Americans want the uninsured to have access to coverage and care, but altruism has limits. They are not willing to accept any weakening of their own employment-based health benefits as a trade-off.
"People are leery about great big ideas" in health care reform, said Michael McKenna, president of MWR Strategies in Washington, a research firm whose clients are mainly aligned with the Republican Party. "People are hesitant to give the government a lot of power in this area."
There is pervasive cynicism about the government's ability to do things well, he said. People evaluate proposed solutions on the basis of self-interest, McKenna said. If they can't anticipate the effect of a public or private initiative, or if they think it will hurt them, they oppose it.
The public, regardless of political affiliation, approves of the way health care is financed, a blend of contributions from employers, individuals and the government, said Sara Collins, a senior program officer with the Commonwealth Fund, a private foundation that supports research on health and social policy.
Two-thirds of voters believe their taxes and health costs will increase if the federal government insures the uninsured, Lake said. By a slimmer margin, a majority say they are willing to pay more taxes to broaden health coverage, even though their wages have stagnated, Lake said.
The basis of this support is shaky, and the concern for others is seasoned with self-interest. Lake said voters want to see progress in stemming health care inflation, and they don't trust the key players - the federal government, corporations, drug makers and insurance companies - to do the job.
By comparison, Americans think small businesses wear halos, because they create jobs that stay in the community. Voters will not support health policies that could harm those companies.
This complicates the search for solutions, because nearly 50 percent of uninsured workers are either self-employed or work for firms with fewer than 25 employees, the Commonwealth Fund's Task Force on the Future of Health Insurance estimates.
Small businesses lack the number of employees needed to provide bargaining clout with insurers, and high rates reflect that. As a result, many have been unable or unwilling to provide group health coverage.
No proposal to increase coverage of the uninsured has the support of the majority of voters, said Robert Blendon, a professor of health policy and political analysis at the John F. Kennedy School of Government at Harvard University.
Some Americans want tax credits to subsidize their own insurance purchases, Blendon said. Others want to provide health insurance for all, which would mean tax increases.
Government-sponsored, single-payer insurance is the least popular alternative. Expanding Medicaid coverage for children gets the most support.
The lack of public consensus allows Congress to dodge a productive debate on comprehensive reform, Blendon said.
"The more ideas you have on the table, the more people can't agree. These proposals are unbelievably subject to challenge by opponents," he said. "The public has no understanding about anything to do with these proposals. They are very vulnerable to what they are told."
Blendon predicts that when experts hit the talk shows and rhetoric clouds the end goal, the nation will splinter, stalling meaningful reform.
McKenna said politicians talk about the "problem" of health care. "That means they don't have a solution. Politically, I don't think anybody has a great answer."
Given the complexities of financing and delivery, Lake said it is easy to seduce voters with bad partial solutions. And incremental fixes will perpetuate a deeply flawed system, she said.
Incremental change may not be the most desirable path, but it may be the most achievable, considering the White House projects a federal budget deficit of $445 billion this year, Blendon said.
Health care must compete for funding, because Americans want a lot of problems solved, he said. "They want public schools fixed, Medicare to have a good drug benefit and the terrorists to leave us alone."
Taking the initiative
With so much at stake and so little consensus, states and private foundations as well as business and community leaders are going where the federal government fears to tread.
They are launching initiatives aimed at broadening coverage, putting the brakes on health care inflation and improving the quality of care.
Medicare and several commercial health plans are piloting programs. These would pay higher amounts to doctors and other health providers who meet quality standards or routinely follow protocols that have been shown to improve patient outcomes.
In May, the HR Policy Association unveiled a plan to make affordable insurance available to 4 million part-time employees, contract and temporary workers, younger retirees not yet eligible for Medicare and college students no longer covered under their parents' insurance.
Anheuser-Busch Cos., Emerson and Caterpillar Inc. are among 50 Fortune 500 companies sponsoring this initiative. The program will be open to eligible people connected with participating companies.
In announcing the program, J. Randall MacDonald, head of human resources for IBM, said the country's biggest employers want to be a force for improvement. "We're not a cure-all. The root causes of problems like the uninsured and sharply escalating health costs are far too complex to be solved overnight."
The association will create large regional pools of people and offer those enrolled the choice of a half-dozen insurance programs. The variety recognizes that the uninsured come in all ages and incomes.
Insurers can bid to sell the products to members of the regional pools. The premiums will not be subsidized by the employers.
The association hopes to offer the insurance by early next year, said Marisa Milton, an attorney for the group.
Later, the group plans to pilot programs to push health insurers to share information about provider quality and efficiency. The association also plans to combine small businesses into larger pools and solicit bids from insurers that are willing to offer discounts comparable to the ones given to jumbo employers.
"We are hoping that by helping out smaller vendors, we might stem the tide from those who are dropping (health insurance)," Milton said. "We doubt that we will be able to make it so attractive that companies not offering insurance will start."
Homemade remedies
Robert Porter, a St. Louis-area health care leader, does not expect state or federal governments to present neat solutions that will broaden access and eliminate disparity. There is no pot of money to throw at the problems.
Porter contends that sustainable solutions must be forged close to home, by pragmatists willing to take a leap of faith.
He reversed a deep decline at DePaul Hospital before moving to his current job as executive vice president for strategy and business development at SSM Health Care-St. Louis.
To shore up DePaul, Porter reorganized services. Then, to save north St. Louis County's only remaining trauma center, he reached out to the community and leaders of competing health systems. The hospital secured state, county and private subsidies to continue trauma services in North County.
Porter said SSM has a mission to attend to the suffering of people, without regard for their ability to pay for care. But to fulfill that mission, the Catholic nonprofit hospital system must be "extremely good" at the business of health care, he said.
That means making sure that mundane and sophisticated tasks alike are handled efficiently. It also means the system must collect from insurance companies and from the patients who have the means to pay.
"In my industry, people are afraid if they don't secure the business enterprise first and limit how much we commit ourselves to serve the poor, we could be in jeopardy. So we will do what we can," Porter said.
People in the United States are afraid to commit to the idea "that every person ought to have access to health care and similar health outcomes, without respect to their circumstances in life," he said. "We are afraid to commit to that, because we are afraid there won't be enough, and we have plenty."
Americans can wait for someone to supply a new source of money, he said, "or we can find it in ourselves to use what we have in our community more intelligently. We have to start chipping away at what we can do."
For example, members of the faith community could help hospital patients make the transition home, keeping tabs on whether they are eating properly and taking medications as prescribed, Porter said.
"There are things we could do now to help one another that do not require a lot of money," he said.
Reporter Judith VandeWater
E-mail: jvandewater@post-dispatch.com
Phone: 314-340-8201
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