US ready for healthcare reform, conference told
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39542.551574.DB (Published 10 April 2008) Cite this as: BMJ 2008;336:797The United States finally has a chance to reform health care, said Len Nichols, director of the health policy programme of the New America Foundation, a non-profit public policy institute based in Washington and California, at a conference on innovation in health care in San Diego last month.
The main driver, said Dr Nichols, is the cost of health insurance to middle class families. In 1987 the median spend on health insurance was 7% of family income, but now it’s 17%. Cost was also a driver of the failed reforms of Hillary Clinton, but last time the pain was caused by the recession and went away when the recession ended. “Now,” said Dr Nichols, “it’s systemic.”
Another crucial driver is the cost to business, accompanied by the growing intensity of international competition. Every year the costs to US businesses of insuring their employees are growing faster than their revenues.
Health costs to US employers are more than twice the average for those of their trading partners such as the United Kingdom, Canada, or Germany. Corporations, which are powerful in the US political system, will be key to making reform happen.
Consumers, and particularly employers, are also recognising the costs of “spotty quality.” They understand that not all hospitals provide the same quality of care and that poor care is expensive. Other drivers are fear of the consequences of being uninsured (some 100 million people are uninsured at some point in a year) and recognition of the high cost to all of uninsured people.
People outside the US tend to think that uninsured people do not get any care, but they have a right to emergency care and attend emergency departments when sick. Hospitals meet these costs by charging insured patients more.
Dr Nichols works with both Democrats and Republicans and finds that important people on both sides are beginning to come together. Democrats traditionally stand for universal coverage and a single payer, the government, but now they are interested in cost and quality as well as coverage and are willing to discuss markets and choice. Republicans are recognising that not everybody can afford health insurance. Republicans are talking about “all” being covered, and Democrats are accepting that there must be “limits.”
Politicians in Washington, DC, have watched bipartisan health reform movements in Massachusetts and California and have been tempted to follow. The Wyden-Bennett bill for healthcare reform that is being discussed in Congress has support from senior politicians from both sides.
In his vision of a better future for health care in the US, Dr Nichols placed great emphasis on better health information systems. Currently the US lags far behind other developed countries in the use of information technology.
Also important, he says, is realigning incentives so that providers are rewarded for providing value rather than simply for providing a lot of ineffective care. At the moment, fee for service combined with low cost sharing and a poor evidence base leads to poor but expensive care. So Dr Nichols also wants to see a “turbo charged drive” to create a better evidence base on what works. He would like to see less money spent on devising new treatments and more on what works.
The main barrier to reform is cost, but Dr Nichols pointed out that the cost of doing nothing is also high. Ian Morrison, former president of the Institute for the Future, another leading health commentator, who spoke at the end of the conference, was less sanguine about reform.
He thought the most likely outcome was “throwing more money” at what he called “pimp my ride health care.” Pimp my Ride is a television programme in which people add luxurious fittings and huge sound systems to their cars but do nothing to the engine.
Footnotes
Richard Smith also spoke at the conference and had his expenses paid by the organisers, McKinsey and Versant Ventures.
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