Might as well read it, folks. What Hillary wants will be strongly considered by Congress.
Now Can We Talk About Health Care?
By HILLARY RODHAM CLINTON - NYT MAGAZINE - COVER STORY
Hillary Rodham Clinton is a Democratic senator from New York.
I know what you're thinking. Hillary Clinton and health care? Been there. Didn't do that!
No, it's not 1994; it's 2004. And believe it or not, we have more problems today than we had back then. Issues like soaring health costs and millions of uninsured have yet to fix themselves. And now we are confronting a new set of challenges associated with the arrival of the information age, the technological revolution and modern life.
Think for a moment about recent advances in genetic testing. Knowing you are prone to cancer or heart disease or Lou Gehrig's disease may give you a fighting chance. But just try, with that information in hand, to get health insurance in a system without strong protections against discrimination for pre-existing or genetic conditions. Each vaunted scientific breakthrough brings with it new challenges to our health system. But it's not only medicine that is changing. So, too, are the economy, our personal behaviors and our environment. Unless Americans across the political spectrum come together to change our health care system, that system, already buckling under the pressures of today, will collapse with the problems of tomorrow.
Twenty-first-century problems, like genetic mapping, an aging population and globalization, are combining with old problems like skyrocketing costs and skyrocketing numbers of uninsured, to overwhelm the 20th-century system we have inherited.
The way we finance care is so seriously flawed that if we fail to fix it, we face a fiscal disaster that will not only deny quality health care to the uninsured and underinsured but also undermine the capacity of the system to care for even the well insured. For example, if a hospital's trauma center is closed or so crowded that it cannot take any more patients, your insurance card won't help much if you're the one in the freeway accident.
Let's face it -- if we were to start from scratch, none of us, from dyed-in-the-wool liberals to rock-solid conservatives, would fashion the kind of health care system America has inherited. So why should we carry the problems of this system into the future?
21st-Century Problems
At the dawn of the last century, America was coping with the effects of the industrial revolution -- crowded living conditions, dangerous workplaces, inadequate sanitation and infrastructure in cities and pollution and infectious diseases like typhoid fever and cholera that exacted a huge toll on the oldest and youngest in society.
Since then, a century's worth of advances yielded remarkable results. Antibiotics were developed. Anesthesia was improved. Public health programs like mosquito control and childhood immunizations succeeded in reducing or even eradicating diseases like malaria and polio in this country. Congress passed legislation regulating the quality of food and drugs and assuring that safety and science guided medical developments. Workplace and product-safety standards resulted in fewer deaths and injuries from accidents. Effective campaigns cut tobacco use and alcohol abuse. Employers began providing some workers with health care coverage, primarily for hospitalization costs. And to aid some of those left out, President Lyndon B. Johnson persuaded Congress to establish Medicare and Medicaid to address the poorest, sickest, oldest and highest-risk patients in our society. As a result of these accumulated gains, life expectancy grew from 47 years in 1900 to 77 years for those born in 2000.
As astounding as those changes were, we are likely to see even more revolutionary changes in the next 100 years. Advances in medicine coincide with advances in computers and communications. The American workplace is changing in response to global pressures. But even positive advances may come with a negative underside. Our affluence contributes to an increasingly sedentary lifestyle that, combined with a diet filled with sugar and fat-rich foods, undermines our ability to fend off chronic diseases like diabetes. And research is proving that the pollutants and contaminants in our environment cause disease and mortality.
It is overwhelming just thinking about the problems, never mind dealing with them. But we have to begin applying American ingenuity and resolve or watch the best health care system in the world deteriorate.
Medical Advances
The pace of scientific development in medicine is so rapid that the next hundred years is likely to be called the Century of the Life Sciences. We have mapped the human genome and seen the birth of the burgeoning field of genomics, offering the opportunity to pinpoint and modify the genes responsible for a whole host of conditions. Scientists are exploring whether nanotechnology can target drugs to diseased tissues or implant sensors to detect disease in its earliest forms. We can look forward to ''designer drugs'' tailored to individual genetic profiles. But the advances we herald carry challenges and costs.
Think about the potential for inequities in drug research. Today, pharmaceutical and biotech companies have little incentive to research and develop treatments for individuals with rare diseases. Never heard of progeria? That's the point. This fatal syndrome, also called premature-aging disease, affects one in four million newborns a year. It's rare enough that there is no profit in developing a cure. This is known as the ''orphan drug'' problem. Genetic profiles and individualized therapies have the potential to increase the problem of orphaned drugs by further fragmenting the market. Even manufacturers of drugs for conditions like high blood pressure might focus their efforts on people with common genetic profiles. Depending on your genes, you could be out of luck.
The increasing understanding and use of genomics may also undermine the insurance system. Health insurance, like other insurance, exists to protect against unpredictable, costly events. It is based on risk. As genetic information allows us to predict illness with greater certainty, it threatens to turn the most susceptible patients into the most vulnerable. Many of us will become uninsurable, like the two young sisters with a congenital disease I met in Cleveland. Their father went from insurance company to insurance company trying to get coverage, until one insurance agent looked at him and said, ''We don't insure burning houses.''
Many have worked to get laws on the books to protect people from genetic discrimination, but we have yet to pass legislation that addresses job security and health coverage. The challenges do not stop there. Health insurance will have to change fundamentally to cope with predictable, knowable risks. Will health insurance companies offer coverage tailored to a person's future health prospects? Right now, if you have asthma, or even just allergies, insurers in the individual market can exclude your respiratory system from your health insurance policy. Will all health plans stop offering benefits that relate to genetic diseases?
The ability to predict illness may overwhelm more than just the insurance system; it may overwhelm the patient and the provider. Studies in The Journal of the American Medical Association found that nearly 6 out of 10 patients at risk for breast and ovarian cancer declined a genetic test, and a similar fraction of those at risk for colon cancer also declined testing. Why? One reason is probably to avoid higher insurance premiums. But the decision to undergo genetic testing is a complex one that involves many issues. Positive test results often indicate increased risk but no certainty that a disease will occur. Negative results also come without guarantees. The development of genetic profiles and individual therapies will exponentially increase the amount of information a physician is expected to manage. Instead of remembering one or two drugs for any condition, a physician will have to analyze all the different genetic, demographic and behavioral variables to generate optimal treatment for a patient.
Medical advances have the potential to overwhelm the health care system top to bottom. At the very least, the pace of technological progress is so rapid that our antiquated health care system is ill equipped to deliver the fruits of that progress. But these advances are not occurring in isolation from other factors affecting both how we finance health care and how much care we need and expect.
Globalization
The globalization of our economy has changed everything from how we work as individuals to what we produce as a nation to how quickly diseases can spread. American companies -- and workers -- compete not only with one another but all over the world. It is called competitive advantage, but it can put American businesses and workers at a disadvantage.
The United States' closest economic rivals have mandatory national health care systems rather than the voluntary employer-based model we have. Automakers in the United States and Canada pay taxes to help finance public health care. But in the United States, automakers also pay about $1,300 per midsize car produced for private employee health insurance. Automakers in Canada come out ahead, according to recent news reports, even after paying higher taxes.
At the same time, American companies are outsourcing jobs to countries where the price of labor does not include health coverage, which costs Americans jobs and puts pressure on employers who continue to cover their employees at home.
And many new jobs, especially those in the service sector and part-time jobs, don't include comprehensive health benefits. More uninsured and underinsured workers impose major strains on a health system that relies on employer-based insurance. In addition, the failure of government to help contain health costs for employers has led to a fraying of the implicit social contract in which a good job came with affordable coverage.
Gone are the days when a young person would start in the mail room and stay with the company until retirement. Employee mobility is now the rule rather than the exception. Those who pay for health care -- insurance companies and employers -- increasingly deal with employees who change jobs every few years. This has the effect of not only increasing the numbers of uninsured but also of decreasing the incentive for employers to underwrite access to preventive care.
At the same time, war, poverty, environmental degradation and increased world travel for business and pleasure mean greater migration of people across borders. And with people go diseases. The likes of SARS can travel quickly from Hong Kong to Toronto, and news of a strange flu in Asia worries us in New York. Welcome to the world without borders.
The Pulitzer Prize-winning science writer Laurie Garrett has described it as ''payback for decades of shunning the desperate health needs of the poor world.'' No matter the blame, the need to act now to address issues of global health is no longer just a moral imperative; it is self-interest.
Lifestyle and Demographic Changes
One hundred years ago, who could have predicted that living longer would be a problem?
In three decades, the number of Medicare beneficiaries will double. By the year 2050, one in five Americans will be 65 or older. We will have to find a way to finance the growing demand not only for health care but also for long-term care, which is now largely left out of Medicare.
Our society's affluence is only half of the story. Widening disparities in wealth and in health care too often cleave along ethnic lines. Today, a Hispanic child with asthma is far less likely than a non-Hispanic white child to get needed medication. African-Americans are systematically less likely to get state-of-the-art cardiac care. As our country becomes more and more diverse, these disparities become more obvious and more intolerable.
Our changing lifestyles also contribute to behavior-induced health problems. We can shop online, order in fast food, drive to our errands. Entertainment -- movies, TV, video games and music -- is one click away. The physical activity required to get through the day has decreased, while the pace and stress of daily life has quickened, affecting mental health. Persistent poverty, risky behaviors like substance abuse and unprotected sex and pollution from cars and power plants all add to the country's health problems. As Judith Stern of the University of California at Davis so aptly put it, genetics may load the gun, but environment pulls the trigger.
Old Problems Persist
If all we had to do was face these tremendous changes, that would be daunting enough. But many of the systemic problems we have struggled with for decades -- like high costs and the uninsured -- are simply getting worse.
In 1993, the critics predicted that if the Clinton administration's universal health care coverage plan became law, costs would go through the roof. ''Hospitals will have to close,'' they said, ''Families will lose their choice of doctors. Bureaucrats will deny medically necessary care.''
They were half-right. All that has happened. They were just wrong about the reason.
In 1993, there were 37 million uninsured Americans. In the late 90's, the situation improved slightly, largely because of the improved economy and the passage of the Children's Health Insurance Program. But now some 43.6 million Americans are uninsured, and the vast majority of them are in working families.
While employer-sponsored insurance remains a major source of coverage for workers, it is becoming less accessible and affordable for spouses, dependents and retirees. In 1993, 46 percent of companies with 500 or more employees offered some type of retiree health benefit. That declined to 29 percent in 2001. When you think about the new economy and worker mobility, it's no wonder employers are dropping retiree health benefits. You can only wonder how many yet-to-retire workers are next.
Even those Americans not among the ranks of the uninsured increasingly find themselves underinsured. In 2003, two-thirds of companies with 200 or more employees dealt with increasing costs by increasing the share that their employees had to pay and dropping coverage for particular services. With rising deductibles and co-pays, even if you have insurance, you may not be able to afford the care you need, and some benefits, like mental health services, may not be covered at all.
The problem of the uninsured and underinsured affects everyone. A recent Institute of Medicine study estimates that 18,000 25- to 64-year-old adults die every year as a result of lack of coverage. But even if you are insured, if you have a heart attack, and the ambulance that picks you up has to go three hospitals away because the nearby emergency rooms are full, you will have suffered from our inadequate system of coverage.
If, as a nation, we were saving money by denying insurance to some people, you could at least say there's some logic to it -- no matter how cruel. But that's not the case. Despite the lack of universal coverage in our country, we still spend much more than countries that provide health care to all their citizens. We are No. 1 in the world in health care spending. On a per capita basis, health spending in the United States is 50 percent higher than the second-highest-spending country: Switzerland. Our health costs now constitute 14.9 percent of our gross domestic product and are growing at an alarming rate: by 2013, per capita health care spending is projected to increase to 18.4 percent of G.D.P.
What drives skyrocketing spending? The cost of prescription drugs rose almost twice as fast as spending on all health services, 40 percent in just the last few years.
Hospital costs have been rising as well, in large measure because more than one in four health care dollars go to administration. In 1999, that meant $300 billion per year went to pay for administrative bureaucracy: accountants and bookkeepers, who collect bills, negotiate with insurance companies and squeeze every possible reimbursement out of public programs like Medicare and Medicaid. Asthma and other pulmonary disorders linked to pollution contribute significantly to these costs, according to the health economist Ken Thorpe. Diabetes, high blood pressure and mental illness are also among the conditions that keep these costs rising.
If we spend so much, even after administrative costs, why does the United States rank behind 47 other countries in life expectancy and 42nd in infant mortality?
A lot of the money Americans spend is wasted on care that doesn't improve health. A recent study by Dartmouth researchers argues that close to a third of the $1.6 trillion we now spend on health care goes to care that is duplicative, fails to improve patient health or may even make it worse. A study in Santa Barbara, Calif., found that one out of every five lab tests and X-rays were conducted solely because previous test results were unavailable. A recent study found that for two-thirds of the patients who received a $15,000 surgery to prevent stroke, there was no compelling evidence that the surgery worked.
In situations in which the benefits of intervention are clear, many patients are not receiving that care. For example, few hospitalized patients at risk for bacterial pneumonia get the vaccine against it during their hospital stays. A recent study in The New England Journal of Medicine by Elizabeth McGlynn found that, overall, Americans are getting the care they should only 55 percent of the time.
As a whole, our ailing health care system is plagued with underuse, overuse and misuse. In a fundamental way, we pay far more for less than citizens in other advanced economies get.
How We Deliver Care
There is no ''one size fits all'' solution to our health care problems, but there are common-sense solutions that call for aggressive, creative and effective strategies as bold in their approach as they are practical in their effect.
First, the way we deliver health care must change. For too long our model of health care delivery has been based on the provider, the payer, anyone but the patient. Think about the fact that our medical records are still owned by a physician or a hospital, in bits and pieces, with no reasonable way to connect the dots of our conditions and our care over the years.
If we as individuals are responsible for keeping our own passports, 401(k) and tax files, educational histories and virtually every other document of our lives, then surely we can be responsible for keeping, or at least sharing custody of, our medical records. Studies have shown that when patients have a greater stake in their own care, they make better choices.
We should adopt the model of a ''personal health record'' controlled by the patient, who could use it not only to access the latest reliable health information on the Internet but also to record weight and blood sugar and to receive daily reminders to take asthma or cholesterol medication. Moreover, our current system revolves around ''cases'' rather than patients. Reimbursements are based on ''episodes of treatment'' rather than on a broader consideration of a patient's well-being. Thus it rewards the treatment of discrete diseases and injuries rather than keeping the patient alive and healthy. While we assure adequate privacy protections, we need care to focus on the patient.
Our system rewards clinicians for providing more services but not for keeping patients healthier. The structure of the health care system should shift toward rewarding doctors and health plans that treat patients with their long-term health needs in mind and rewarding patients who make sensible decisions about maintaining their own health.
End of part one. |
