Thought Leaders: Medicine
Reform Redux
Len M. Nichols
12/01/2006

Reform of the health care system will very likely be the top domestic issue in the 2008 presidential election. The barometers of health system stress are worse than they were on Bill Clinton’s inauguration day, when health care reform seemed inevitable.

Agreed, Clinton’s effort failed spectacularly. This time around, however, even the wealthiest Americans are starting to see how reform can benefit them. For one thing, money buys you far less quality than many realize. In March, the New England Journal of Medicine reported that Americans with higher income receive good care only 57 percent of the time—not much more often than those with the lowest incomes, who receive good care 53 percent of the time. Though we spend at least twice as much per capita on health care as our major trading partners, our systemwide performance is ranked 37th by the World Health Organization.

Also, American CEOs are now energized to support health care reform as long as cost-containment is a primary element of the program. Wal-Mart CEO Lee Scott made his views on the issue clear in his August 1 interview with Charlie Rose on PBS. "I think we’re getting to a tipping point where this country is going to be willing to move on health care," Scott told Rose. "First of all, business and labor are going to have to participate and probably play even more of a leadership role than government . . . and then bring the political side along with them.

"Isn’t is amazing," Scott continued, "that Wal-Mart sells a package of toilet paper today in Spokane, Wash., and suppliers all know [it] the next day . . . yet when I went for my physical, then had a body scan down the hall, I had to fill out separate paperwork."

World Wellness Web
Reform this time should be about harnessing technology to produce an information system containing electronic health records that can stay up-to-date with one’s history and medications. Paper records in a file in your doctor’s office in New York are not going to help a clinician across the country (or even across town) make the right choices in a hurry.

Consider a story that appeared in the journal Health Affairs last year (September/October 2005). A casino in Las Vegas was easily able to find out that a certain unlucky, but optimistic, gambler had a bad credit rating, and hence denied him credit. Upon hearing this, he passed out. He was taken to a nearby emergency room, where the hospital personnel were unable to verify what medications he was taking and inadvertently killed him.

A medical information system could not only contain personal information, but also decision support tools—for example, short explanatory videos—so that any physician could access state-of-the-art information about complex diagnostic and treatment options. This system is coming in fits and starts already, but it can become a reality much faster if government programs such as Medicare and Medicaid were to require it of providers. There are concerns about privacy, but I think it is fair to assume we are talking about making personal medical information available only to providers, not posting it on the Web.

Malpractice reform is another obvious component of a better delivery system, as is paying providers for preventive health care. These are measures that we could implement in the next three to five years if public and private insurers work together and get congressional support.

What really is driving costs up, however, is the overuse of new technology. We could save trillions of dollars in the long run if public research institutions and private sector companies invest more money and time up front in matching new technologies—drugs, devices and procedures—with truly appropriate patients. Such a move would also help end the incentives that cause our pharmaceutical industry to trumpet minor changes as major gains. It was such perverse logic that led Vioxx to be grossly overprescribed and cause many avoidable deaths, and Viagra to be advertised on ESPN as a lifestyle enhancer, rather than a clinical problem solver.

There are many ways to rebuild the system, with private insurance, subsidies, consumer choice and the other details left for future debates. First, though, we need to reduce the partisan reflux disease on this subject and simply agree that we all have far more to gain from reforms of this type than the zero sum "coverage-only" reforms of the past.

Len M. Nichols is director of the Health Policy Program at the New America Foundation, a nonprofit, nonpartisan public policy institute in Washington, D.C.