Health reform debate: Indiana University experts offer perspectives
Structural changes won't be sufficient
Many doctors support reform
Fair competition v. profits
Disease care or health care?
Is fifth time the charm for national health coverage?
Focus on prevention and primary care
Improving quality is a universal goal
A better workforce is needed
Why dual-track, public and private insurance plans won't work
Delaying reform has raised costs
Reform will fail without prevention
Look to the states for reform
Health care reform has moved to the forefront of President Barack Obama's agenda, Congress is considering legislation, and citizen and interest groups are gearing up for a massive Washington battle. Indiana University experts from the fields of medicine, public health, law, public policy and economics recently shared their perspectives.
Structural changes won't be sufficient. President Obama has proposed increasing investments in prevention, expanding health information technology, new insurance reforms, and developing a national health insurance exchange, with or without a public plan option in order to slow or reverse rising health care costs, notes Eric Wright, director of the Indiana University Center for Health Policy at Indiana University-Purdue University Indianapolis. "While some may disagree with specific recommendations in the President's proposals, stakeholders as well as members of Congress do agree that structural reform in these basic areas is essential," Wright said. "What's missing from the debate, however, is a serious consideration of and policy recommendations for addressing some of the broader socio-cultural trends in our society that contribute to rising health care costs, including ever increasing consumer demand for the latest and greatest drug, medical technology or procedures; a culture that devalues health and stigmatizes illness; and, a population that is poorly educated about their own bodies, illness and health care and that takes their health for granted. Clearly, these trends must be viewed, in large part, as an outgrowth of our fragmented, inefficient and poorly managed health care system. Changing the system in the ways the President proposes may be necessary, but it is hard to imagine that these structural changes will be sufficient to reduce health care costs in the long-run until we also take steps to reshape the way Americans think about and perceive their own health and health care. Top
Many doctors support reform. A growing number of American physicians support health care reform, according to Aaron Carroll, M.D., director of the IU Center for Health Policy and Professionalism (CHPPR), associate professor of pediatrics at the IU School of Medicine and a pediatrician at Riley Hospital for Children. "There is no evidence that physicians oppose a public health insurance option," said Carroll. A study conducted by CHPPR at the IU School of Medicine and published last year in the Annals of Internal Medicine found that 59 percent of physicians would support government legislation for National Health Insurance, a much more radical type of reform than that currently proposed by the Obama administration. Only 32 percent of physicians opposed national health insurance, according to the study. The CHPPR survey of 2,200 physicians showed a 10 percent increase in support for national health insurance from a previous survey. Nearly every medical specialty showed an increase in levels of support for national health insurance. With the exception of radiologists, anesthesiologists and surgical subspecialists, a majority of every medical specialty now support national health insurance, according to the study. Top
Insurance industry concerned about profits, not fair competition, affordable health care. Eleanor Kinney, co-director of the Center for Law and Health and the Hall Render Professor of Law at Indiana University School of Law-Indianapolis, calls for common sense, not ideology or knee-jerk responses, in assessing the the prospect of a new government insurance program in President Obama's health care proposal. The insurance industry and its supporters claim this plan would provide unfair competition for private insurers. "Had the insurance industry been able to come up with health insurance that is affordable, provided good coverage and did not require a public subsidy -- I don't care how much profits the insurance industry makes -- go for it," she said. "But when the insurance industry relies on tax expenditures to pay for their product, it seems to me they should not complain if the government, the source of the funds paying for their product, wants to get into the business, too." Private insurers have benefited for decades from tax deductions provided to employers who provide health insurance to their employees. "That this industry thinks they shouldn't be required to compete with a government-sponsored health insurance program that might be cheaper and more efficient is beyond me, particularly in the face of serious market failure in the market for health care and services," Kinney said. "What they're really protecting is their ability to make large profits, the kind of profits that support seven-figure CEO salaries."
To read Kinney's article, "The Corporate Transformation of Medical Specialty Care: The Exemplary Case of Neonatology," published in the Journal of Law, Medicine and Ethics, visit http://indylaw.indiana.edu/instructors/kinney/articles/Corporate_Transformation_JLME_2009.pdf. Top
Disease care v. health care. While the top three leading causes of death are heart disease, cancer and stroke, the actual causes of premature death are tobacco, lack of physical activity, poor nutrition and other drug abuse, said Mohammad Torabi, chair of the Department of Applied Health Science and Chancellor's Professor of Applied Health Science in IU Bloomington's School of Health, Physical Education and Recreation. He said these actual causes of premature death require public health measures rather than clinical intervention. "Historically, our health care system has not been a true health care system but a disease care system, and that notion has to change," he said. "True health care reform must pay attention with not just lip service but with resources for public health and prevention if it is to have a major impact on true health care and also control the skyrocketing health care costs. Therefore, investment in primary and secondary prevention, which are true public health initiatives, must be an integral part of any health care reform." The second element, he said, is that basic coverage for all Americans is fundamental, not only for controlling health care costs but also for investing in the future of the country. Top
Is fifth time the charm for national health coverage? National health insurance was first proposed in the U.S. almost 100 years ago, noted Stephen J. Jay, M.D., a public health historian and former chairman of the IU School of Medicine Department of Public Health. Yet that proposal by the American Association of Labor Legislation -- and subsequent efforts in the 1940s, 1970s and 1990s -- all failed, despite widespread public support. "The collective public and private responses over the past several decades to the serious problems with cost, access and quality of health care have consisted of incremental, piecemeal reforms," Jay said. "These have resulted in today's dysfunctional health care system that is not competitive on either cost or outcomes of care with most other developed countries in the world. Our system spends little on prevention of disease, focusing instead on 'sick care.' Have we arrived today at a point in time when through public policy all Americans will gain access to quality and affordable health care and preventive services? Only with public engagement in the dialogue, on a scale not seen in decades, will a positive outcome for citizens be the likely result." Top
Focus on prevention and primary care. Access to affordable and high-quality care is uneven across the state of Indiana, says Richard Kiovsky, M.D., professor of clinical family medicine at the IU School of Medicine and program director of the Indiana Area Health Education Centers Program. "For any health reform to be successful, it will need to focus on affordable access to appropriate preventive and primary care services," Kiovsky said. "There are many health care delivery systems in Indiana that are doing a good job at providing cost-effective care to everyone, and others that acknowledge they can do better. Accountability for quality, cost controls and outcomes will be important. There are too many communities that are not currently served for many complex reasons. We must ensure that everyone gets the right care in the right place at the right time and at the right cost with the right outcomes." Top
Improving quality is a universal goal. The partisan fights over health reform are hiding the fact that there's widespread agreement on the need to improve quality, says Nicole Quon, assistant professor in the School of Public and Environmental Affairs at IU Bloomington, who conducts research on health politics, regulatory policy and quality of care. "The debate around health system reform centers on two key goals: expanding health insurance coverage and managing the increasing costs of medical care," Quon said. "The paths to achieving these goals are politically tricky. However, there is another issue that is less contentious and equally important: improving quality. The benefits of focusing on quality include increased efficiency (health information technology), improved health outcomes (chronic disease management programs), and increased patient satisfaction and compliance (medical homes). There is an opportunity now to shape the health care debate. I hope that our elected officials remember that high-quality medical care is a goal that we all support." Top
A better workforce is needed. Shortages of doctors and other health professionals are an impediment to efforts to improve health care, says Terrell Zollinger, professor at the IU School of Medicine and associate director of the Bowen Research Center, the research arm of the school's Department of Family Medicine. "We know that our healthcare system needs to be reformed and expanded to improve health status and reduce costs, but we don't currently have the right health workforce to achieve the most cost-effective care," Zollinger said. "Across Indiana and the nation, we face shortages of physicians and support professionals, especially primary care physicians, in vulnerable communities. Recent trends indicate that those shortages are projected to get worse, not better. As a result, care is delayed and becomes more costly. In anticipation of health care reform at the national level, which would also shape the health care system in our state, the demand for primary care physicians and other health care professionals is expected to increase dramatically in the near term. Consequently, we must start building that workforce now and develop a mechanism to improve their geographic distribution. There are many ways to do that. Clearly reimbursement and practice incentives are part of the formula to achieve the success needed. Another component is to revise admission policies to better target students who are more likely to practice where they are needed. For example, an effective strategy has been to train students who come from those communities, since they are more likely to choose those areas to practice." Top
What we need versus what we'll get. Congress likely will pass some form of health care legislation but Americans should not expect to see universal coverage, says David Orentlicher, M.D. and J.D., co-director of the Center for Law and Health at the IU School of Law-Indianapolis. Orentlicher said legislators likely will expand the faulty dual-track system currently in place. For people under age 65, health care insurance largely is provided either by employers or subsidized government programs for those who cannot afford coverage. But the U.S. has a proven track record for inadequately funding programs for the poor. "Our current approach to health care hasn't worked for 45 years," Orentlicher said. "Congress has to approve subsidies for the poor every year. People with political influence will not back adequate funding for public subsidies when they do not directly benefit from them." It's a different story, however, when everyone is grouped into a single system, he said, citing as examples Medicare, which provides health care insurance for people 65 and older, and Social Security, which provides pension benefits for people 65 and older. "When everyone is in the same system, it can achieve universal access." An option for a single-track government program, Orentlicher said, is an improved version of Republican Sen. John McCain's proposal for a tax credit, which he suggested during his presidential campaign. Instead of giving families a meager tax credit to use to buy their insurance, they could be given a voucher for payment in full of an insurance policy in the private market. To prevent health insurance companies from gaming the system, they would not be able to turn people away for pre-existing conditions or other limiting factors. "I can't see how Republicans could object to a McCain-style proposal," he said. "It's really a free-market kind of approach." Top
Delaying reform has raised costs. The cost of health care reform is bigger than we think, if the liabilities of not having reformed the sector 15 years ago are included, says Alejandro Arrieta, assistant professor in the School of Public and Environmental Affairs at IUPUI. "Our current health care model has created incorrect incentives that have molded quality standards and the overall medical practice in a way that harms the health of Americans," Arrieta said. "The last Agency for Healthcare Research and Quality report on health care quality and disparity in the United States shows deterioration in many quality indicators. Fifteen years ago, only eight women out of every 100,000 live births died from pregnancy-related causes. Today this number has almost doubled. How many lives have been affected due to the lost reform? In a model that encourages over-utilization and inappropriate use of resources, he said, it will take more effort to reverse the deterioration that has been taking place in quality. "One of the most over-utilized procedures in the United States, Caesarean sections, has grown by nearly 40 percent in the last 15 years. Today almost one of every three women has a surgical delivery. Many obstetricians now feel more comfortable performing a C-section than a natural delivery. Medical practices have been shaped by distorted incentives, and this is also a liability that President Obama's health care reform will need to consider." Top
Reform will simply fail without prevention. An economic crisis and a health crisis simultaneously afflict Americans. These crises are synergistic. By 2008, the U.S. spent $2.4 trillion for health care, or 17 percent of our gross domestic product (GDP) -- 75 percent of which went toward treating largely preventable chronic diseases. "We now spend four times more on health care than on defense," said Lloyd Kolbe, associate dean for global and community health for IU Bloomington's School of HPER. "By 2016, we'll pay $4.3 trillion -- 20 percent of GDP for health care. We can't pay for health care in 2009; we certainly won't be able to pay for it in 2016. Worse, U.S. businesses won't be able to compete in a global economy with businesses in other nations that have healthier workforces, and pay less for worker health care." The U.S. spends a greater amount for health care than other nations, Kolbe said, yet it ranks 26th in life expectancy at birth, 32nd in infant mortality, and 35th in child mortality. "Yes, we need health care reform for our nation to assure everyone can receive health care; just as every other industrialized nation, except the U.S., assures. But health care reform only will offer means to pay for health problems that will increase in number and cost, especially as our population ages. It will not appreciably reduce costs. We urgently need public health and health care reform -- combined together -- if we are to reduce ever increasing costs of health care." Public health programs markedly can prevent unnecessary suffering, illness, disabilities, medical care costs, and deaths; yet they remain desperately underdeveloped. How do they become better developed? In Indiana, IU President Michael McRobbie had the vision and courage to take an important step for the state by authorizing the establishment of two complementary schools of public health; one at IU Bloomington and the other at IUPUI (see: http://homepages.indiana.edu/news/page/normal/10780.html). Specific, feasible means to prevent health problems among people throughout the country have been articulated by the best and the brightest health professionals in "Blueprint for a healthier America: Modernizing the federal public health system to focus on prevention and preparedness" (see http://healthyamericans.org/report/55/blueprint-for-healthier-america). Top
Look to the states for reform. It is a myth that our current health care system is "free-market," says Eric Schansberg, professor of economics at Indiana University Southeast. And blaming the market system for U.S. health-care problems "is akin to blaming the Great Depression on markets while ignoring the amazing policy blunders of the government during that time. The extent to which we should blame the government is debatable. But ignoring its role is neither legitimate nor useful," he said. Government intervention extends from Medicare/Medicaid to labor market restrictions, from mandated insurance coverage of marginal services to the explosion of medical malpractice awards. "The most important public policy in this realm? The subsidy of health insurance -- acquired by workers through the firm -- as a non-taxed form of compensation," Schansberg said. "As a result, workers get 'too much' insurance. (Insurance typically covers rare, catastrophic events; health insurance covers everything from allergy shots to cancer.) This drives up costs and links our health insurance to our jobs, creating problems with 'portability' and pre-existing conditions."
Schansberg adds that 1) Extending health care availability almost certainly involves higher costs and/or reduced access in other contexts-- "rationing." 2) President Obama's proposal to subsidize public insurance to "compete" with private insurance "would undermine private insurance to some extent -- somewhere between attracting people at the margin and entirely destroying the industry, depending on the extent of the subsidy," he said. 3) Even if government involvement is effective in other countries, it doesn't imply that the same will be effective in the U.S., with its large, diverse population. "Likewise, why are we so fixated on a federal approach?" Schansberg asked. "Why not allow the 50 states to try 50 different experiments, rather than betting everything on one grand, federal experiment that would be difficult to reverse? Can we really afford to take that chance?" Top