Too much angst, not enough progress

The US has struggled since the 1930s with attempts to enact comprehensive health reform. Most people can easily point out what is wrong with US health care – it’s too expensive, quality is inconsistent, too many people are uninsured and many communities do not have adequate health resources. Changing that dynamic requires that legislators develop a rigorous approach to understanding how we got to this point, examining potential ways to improve results, assessing the risks and then agreeing on remedies.

So why have so many past health reform efforts failed?

When you look back at the unsuccessful attempts throughout the 1900s, one theme emerges – individuals leading the reform efforts failed to comprehend the threat of emotional and economic disruption:

• Strong emotional issues and fears are associated with changing the dynamic of the patient-physician relationship. People want to believe that their personal physicians have patients best interests at heart, not the health plan’s financial interest.

• The health sector represents about 16% of the economy. The organizations within the health sector are diverse and can be at odds with one another. Some of the organizations, such as hospitals and physicians, can become internally fragmented by solutions that change relative income among the participants and create winners and losers.

Ideas that propose to change the status quo and potentially diminish or eliminate roles are bound to be met with strong resistance. Changing our health care system requires that people share a common view of the problems and its underlying causes and solutions. Taking a big leap of faith with 16% of the economy also creates anxiety for lawmakers, who fear repercussions if the ideas fail to achieve desired results. What if we get it wrong? What if costs are not controlled? Perhaps not enough time has been invested in rationalizing the solutions and their impact.

What’s often overlooked is that the US has successfully passed legislation that has expanded coverage for certain segments of the population and changed health delivery. Notable examples of health legislation include:

• Federal passage of Medicare coverage for the elderly and, later, prescription drugs

• Federal passage of Medicaid coverage for low-income individuals and subsequent expansion to address the needs of low-income children

• Statewide mandated medical coverage in Hawaii, Massachusetts and Vermont

• Federal mandates that enabled significant expansion of Health Maintenance Organizations

It appears that it is easier for the US to address narrowly defined problems, but that approach also exacerbates a fragmented health care system.

One of the most contentious issues in the current health reform debate is whether a public program should be introduced for individuals and employees who are currently covered by private insurers or self-insured employer plans. Ironically, the US has separately administered programs for Medicare, Medicaid, Tri-Care, and federal, state and local government employees. There has been no attempt to consolidate those programs into one publicly administered plan. Yet there has been heated debate on introducing a public program that would presumably be administered separately from all the other government programs. The debate detracts attention from the opportunity to improve efficiency and performance of the existing public plans.

Ideas about public plans, single-payer systems and other cost savings are often drawn from observing what’s working in other countries. Does one country have an ideal solution? Or does each country have valuable ideas that would be instructive for our own reform efforts?

The case for change

Available well-developed baseline statistics demonstrate some of the key differences between the US and other developed countries. We limited our comparisons to Australia, Canada, France, Germany, Japan and the United Kingdom, as the cost difference is even greater between the US and statistics for developing countries, statistics are less reliable and we would be comparing very different health care environments.

Cost

There is a clear difference in the cost, which demonstrates why it is becoming increasingly difficult for the US to compete globally against both mature and emerging economies.

Since the US per capita cost is high, it stands to reason the health care consumes a much higher percentage of our overall gross domestic product.

Business Roundtable asked Dr. Arnold Milstein, Mercer’s clinical thoughtleader, to quantify the competitive disadvantage created by our current health care system. Dr. Milstein’s work group identified a “value gap” that places the US at a 23% competitive disadvantage against mature economies and a 46% disadvantage against emerging countries.

Quality

Not only are costs high, but critics point out that as much as a third of the spending is inefficient, unnecessary, and/or produces uneven quality and outcomes. Poor results are attributed to providers’ lack of adherence to evidence-based guidelines, ineffective coordination of care for complex illnesses, lack of shared medical records, and inefficient use of inpatient and emergency room care when lower-cost options would suffice. Poor outcomes are also attributed to noncompliant patients who don’t follow treatment plans, stop taking or can’t afford their medications, and have unhealthy lifestyles.

Access to coverage

Individual health coverage is both expensive and difficult to find. As the recession drives the uninsured population close to 20%, there is growing pressure to resolve what is viewed as a social and moral embarrassment for such a wealthy nation.

Access to providers

Many communities suffer from an insufficient supply of health providers, particularly for primary care services. Payment systems have created incentives for physicians to become specialists. The underserved population (the percentage of the population living in areas with primary care physician shortages) ranges from a high of 34.4 percent in Louisiana to a low of 1.7 percent in New Jersey.

Population health

In theory, spending more money on health care should result in longer, more productive lives. However, the statistics indicate that Americans don’t live longer.

The health status of the US population may explain some of the difference in spending. Obesity, in particular, is not just increasing current expense, but creating a ticking time bomb for future health costs.

Read the second part of the article: Lessons learned from other countries'