January 16, 2009
12:01 a.m. Eastern Time
The Prospects For Health Reform: Leading Experts Outline A Health Policy Agenda For The Obama Administration And Congress
Bethesda MD -- Will the incoming Obama administration and the new Congress succeed in enacting health reform? What might reform look like, and how will business partner with government to improve the health care system? What should the new administration's global health agenda look like?
In a pre-inaugural package of eight papers released today on the Health Affairs Web site, Members of Congress, business, policy, and academic leaders offer their thoughts on the prospects for reform and their advice on what the nation's health policy agenda should be at home and around the globe.
Summaries of the papers appear below.
Health Reform: A Bipartisan View, by Jim Cooper and Michael Castle. President-elect Barack Obama has a real chance to achieve health care reform and universal coverage, particularly if he acts within the first six months of his administration, senior Congressman Jim Cooper (D-TN) and Rep. Michael Castle (R-DE) assert. Cooper and Castle point out that the cost of achieving universal coverage now seems modest compared to the cost of the various financial bailouts undertaken by the federal government; they add that the cost of expanding coverage may possibly be offset by reducing waste in the health care system. The two House members predict that partisan bickering will present a serious but not insurmountable obstacle to health reform, and they suggest that fears of opposition to reform from interests such as the insurance industry and small business may be overrated. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.2.w169
Cooper and Castle say that the existence of the Healthy Americans Act, sponsored by Sen. Ron Wyden (D-OR) and Sen. Robert Bennett (R-UT), could give the Obama administration an important head start on health reform. Wyden-Bennett has some controversial aspects and represents a beginning rather than a finished work, say the two legislators, both of whom are cosponsors of Wyden-Bennett. However, the bill's moderate content and its bipartisan support in both chambers of Congress suggest that "it can be a basis for the inevitable compromises that must be made to assemble a package palatable to most Americans."
Health Care Reform: Why We Cannot Afford To Fail, by Denis Cortese and Jeffrey Korsmo. Health care reform is necessary and requires major action not just by government, but also by the health care industry, say Denis Cortese, president and CEO of Mayo Clinic, and Jeffrey Korsmo, executive director of the Mayo Clinic Health Policy Center. Cortese and Korsmo advance "four broad cornerstones" of reform. The first two cornerstones -- creating value through improved health outcomes and service to patients, and coordinating care -- must be addressed primarily by the health care industry, while government should take the lead on reforming the payment system and providing insurance for all, the two Mayo Clinic executives say. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.2.w173
Cortese and Korsmo agree with incoming Health and Human Services Secretary Tom Daschle on the need for a U.S. Health Board, an independent board made up of providers, payers, and patients that could insulate health care decision making from the politics of Capitol Hill. One of the first tasks of such a Health Board should be to devise new payment mechanisms for the health care system, according to Cortese and Korsmo. "When we talk with members of Congress about health care costs, we hear a common refrain: ‘We're not getting what we pay for.' But in fact, we are. Because our reimbursement system rewards piecework -- performing diagnostic tests and procedures -- it's natural that our health care is laden with these expensive, fragmented pieces of care," the authors write.
Health Care Transformation And CEO Accountability, by Craig Barrett and Peter Lee. Unless President-elect Obama -- America's CEO -- and the CEOs who run America's large businesses work together, meaningful, successful health reform will not occur, say Craig Barrett, chairman of the board of the Intel Corporation, and Peter Lee, executive director for national health policy at the Pacific Business Group on Health. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.2.w177
Barrett and Lee say that the high costs associated with the nation's inefficient and outdated health care system are putting American companies at a competitive disadvantage and squeezing the wages of American workers. Yet health reform discussions too often focus on merely shifting costs rather than reducing them.
"For too long, employers have tolerated poor care, done little to control costs, and placed avoiding disruption for employees ahead of any concerted commitment to improvement and efficiency," Barrett and Lee write. "CEOs must now be accountable for how they engage with government as part of the solution to our health care woes." They add that "President-elect Obama would do well to speak the language of CEOs" since the innovation needed to help reengineer the health care delivery system "has always been at the core of successful U.S. companies."
Barrett and Lee cite several examples of ways that Intel, PBGH, and others from the business community are working to make the health care system more cost-effective and patient-centered, and they call upon all CEOs to become personally involved in fundamental health care change. "If you are a corporate CEO and you just send this Perspective down your human resources chain of command for follow-up, you've missed the point," they write.
Health Reform: Getting the Essentials Right, by Victor Fuchs. To be successful, any health reform plan must include certain essential elements, writes Victor Fuchs, the Henry J. Kaiser Professor Emeritus at Stanford University. In particular, any plan should include the "four Cs": truly universal coverage; cost control; coordinated care; and choice. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.2.w180
There are a number of ways to achieve each of these elements, Fuchs points out. For example, policymakers might seek universal coverage through a combination of individual and employer mandates along with generous subsidies for those who cannot afford coverage, as in Massachusetts; through a single-payer "Medicare-for-all" approach; or through a universal voucher approach leaving people free to choose among competing health plans, as in the Dutch and Israeli systems.
Fuchs notes that it is easy to disagree about the details of anything that substantially changes 16 percent of the U.S. gross domestic product. "Failure because of such disagreements is always the easiest course, as the ninety-year history of health reform has demonstrated," Fuchs observes, but he urges policymakers to keep their focus on the essential "four Cs" and to realize that they will not be able to get all the details correct right away. "Enactment of the essentials with a flexible framework that permits easy midcourse corrections and adjustments can, by successive approximations, get the details right," he concludes.
The Pitfalls Of Overreaching In Health Reform, by Henry Aaron. Sweeping health reform efforts may well fall short, warns Henry Aaron, the Bruce and Virginia MacLaury Senior Fellow at the Brookings Institution. He points out that the U.S. health care system is larger than the economy of France, and "it's not typical of democracies to transform something the size of all of France through a single piece of legislation, or even through multiple laws during a single presidency." This is particularly true since "the very features of the health care system that cry out for reform" -- such as the system's "chaotic disorganization" -- "also militate against successful ‘big bang' changes." http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.2.w184
Aaron reminds readers that the one great success in health policy over the past decade -- the increase in the proportion of insured children -- came about not through sweeping reform but through "highly technical, piecemeal extensions of Medicaid during the 1980s and enactment of the State Children's Health Insurance Program in the 1990s." He suggests focusing on four relatively narrow but achievable reforms: (1) strengthening health information technology; (2) expanding cost-effectiveness analysis; (3) creating a national health insurance clearinghouse; and (4) providing federal financial support to states that undertake coverage expansions. Achieving these limited steps "should be seen not as failure, but rather as a great victory that lays the groundwork for a sustainable process of change that will continue long after today's reformers are gone," Aaron says.
A New Approach To The State-Federal Relationship In Health, by Alan Weil. "Before it introduces a single piece of legislation or promulgates one regulation, the Obama administration should commit to healing the relationship between the federal government and the states in health care," writes Alan Weil, executive director of the National Academy for State Health Policy. Weil states that federal policy making is too often shaped by mistrust of the states, particularly concerning Medicaid, which dominates federal-state health care interactions. According to Weil, the federal government views states as unwilling to pay their fair share of Medicaid costs, incapable of or uninterested in designing effective programs, and inattentive to the needs of Medicaid enrollees. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.2.w188
Weil faults the federal government's current practice of micromanaging state Medicaid programs through secretive, detailed reviews of state requests for waivers of federal Medicaid rules. He advocates the establishment of performance benchmarks for states and says that over time, federal oversight "should migrate from line-by-line state plan scrutiny toward accountability for performance and improvement."
Weil also argues for strengthened federal partnerships with the states in areas such as payment reform, provider supply and licensure, reducing racial and ethnic disparities, improving the regulation of insurance markets, and strengthening the financing of the safety net. Additionally, he calls for reexamining how the federal government and the states divide responsibility for those eligible for both Medicare and Medicaid; the dual eligibles "should experience a single, integrated program designed to promote their health and well-being," Weil says.
Don't Forget About The Social Determinants Of Health, by Gail Wilensky and David Satcher. As the United States moves to reform its health care system, it is important to recognize the importance of the so-called "social determinants" of health, Gail Wilensky and David Satcher stress. These social determinants include income and educational levels, the status and treatment of women, and employment opportunities, among other factors. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.2.w194
"The importance of the social determinants of health is perhaps most obvious for developing countries," the authors write. "What may be less obvious is that these same social and economic factors are important in determining health outcomes in the developed world as well," continue Wilensky, a senior fellow at Project HOPE (the publisher of Health Affairs) and former administrator of the Health Care Financing Administration under President George H.W. Bush, and Satcher, director of the Satcher Health Leadership Institute at the Morehouse School of Medicine and former Surgeon General under President Bill Clinton. Wilensky and Satcher have served together for three years as commissioners on the World Health Organization's Commission on the Social Determinants of Health.
Focusing on the social determinants of health is particularly important for children, Wilensky and Satcher argue. "In fact, many of the most vexing health problems we face now and are projected to face in the future have their roots in the early years of life," the authors point out. They offer several strategies aimed at improving the health of children, such as improving child care and early childhood education, ensuring that all pregnant women who want to enroll in substance abuse programs can do so, and including temporary extensions of food stamp and unemployment insurance benefits in the economic stimulus package that Congress is considering.
Global Health For A Globally Minded President, by Nils Daulaire. By building on the historic initiatives championed by his predecessor to fight the global HIV/AIDS and malaria epidemics, President-elect Obama can save millions of lives, says Nils Daulaire, president and chief executive of the Global Health Council. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.2.w199
"Continuity and expansion of some of Bush's hallmark disease-fighting initiatives needs to be coupled with key policy modifications and a new, more comprehensive commitment to improving the health of families everywhere," Daulaire writes. He asserts that these actions could save more than six million lives annually by the end of Obama's presidency.
Daulaire urges Obama to launch a Global Family Health Action Plan. This plan would be designed to dramatically reduce deaths among the estimated nine million children who die each year from causes such as pneumonia, diarrhea, and vaccine-preventable diseases, as well as the half-million women who die annually from pregnancy- or childbirth-related complications. The plan would also aim to reduce the seventy-six million pregnancies that occur each year.
Daulaire urges Obama to continue and strengthen Bush's signature global health initiatives, such as the President's Emergency Plan for AIDS Relief and the President's Malaria Initiative. Daulaire also urges the president-elect to bring efforts to fight tuberculosis "out of the shadows" and to expand efforts to address neglected tropical diseases, such as lymphatic filariasis and schistosomiasis. In addition, Daulaire says Obama should rescind policy directives that work counter to the goal of improving global health, particularly in the areas of family planning and reproductive health.
After the embargo lifts, the articles described above will be available at http://content.healthaffairs.org/cgi/content/full/hlthaff.28.2.w169/DC3
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Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org. The full text of each Health Affairs Web Exclusive is available free of charge to all Web site visitors for a two-week period following posting, after which it will switch to pay-per-view for nonsubscribers. Web Exclusives are supported in part by a grant from the Commonwealth Fund.
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