Can we talk about health care - part two
Harnessing Modernization
As paradoxical as it is that advances in medical technology could potentially break our antiquated system, advances in other technologies may hold the answer to saving it. Using a 20th-century health care system to deal with 21st-century problems is nowhere more true than in the failure to use information technology.
Ten years ago, the Internet was used primarily by academics and the military. Now it is possible to imagine all of a person's health files stored securely on a computer file -- test results, lab records, X-rays -- accessible from any doctor's office. It is easy to imagine, yet our medical system is not there.
The average emergency-room doctor or nurse has minutes to gather information on a patient, from past records and from interviewing the patient or relatives. In the age of P.D.A.'s, why are these professionals forced to rely on a patient's memory?
Information technology can also be used to disseminate research. A government study recently documented that it takes 17 years from the time of a new medical discovery to the time clinicians actually incorporate that discovery into their practice at the bedside. Why not 17 seconds?
Why rely solely on the doctor's brain to store that information? Computers could crunch the variables on a particular patient's medical history, constantly update the algorithms with the latest scientific evidence and put that information at the clinician's fingertips at the point of care.
Americans may not be getting the care they should 45 percent of the time, but the tools exist to narrow that gap. Research shows that when physicians receive computerized reminders, statistics improve exponentially. Reminders can take the form of an alert in the electronic health record that the hospitalized patient has not had a pneumonia vaccine or as computerized questions to remind a doctor of the conditions that must be fulfilled before surgery is considered appropriate.
Newt Gingrich and I have disagreed on many issues, including health care, but I agree with some of the proposals he outlines in his book ''Saving Lives and Saving Money,'' which support taking advantage of technological changes to create a more modern and efficient health care system. I have introduced legislation that promotes the use of information technology to update our health care system and organize it around the best interests of patients. Improvements in technology will end the paper chase, limit errors and reduce the number of malpractice suits.
I strongly believe that savings from information technology should not just be diffused throughout the system, never to be recaptured, but should be used to make substantial progress toward real universal coverage. By better using technology, we can lower health care costs throughout the system and thereby lower the exorbitant premiums that are placing a financial squeeze on businesses, individuals and the government. At the same time, some of those savings should be used to make substantial progress toward real universal coverage. (I may have just lost Newt Gingrich.)
Taking the Broader View: Public Health And Prevention
While we focus on empowering the individual through technology, we also have to recognize the larger factors that affect our health -- from the environment to public health.
If asthma and other pulmonary disorders are the main drivers of increased health spending, that argues strongly that we should rethink how social and environmental factors impact our collective health. Consider that over the last century we have extended life expectancy by 30 years but that only 8 of those years can be credited to medical intervention. The rest of our gains stem from the construction of water and sewer systems, draining mosquito-infested swamps and addressing spoilage, quality and nutrition in our food supply. Yet we continue to underinvest in these important systematic measures -- resulting in expensive health consequences like the explosion of asthma among children living in New York City or the harmful levels of lead found among children drinking water from the District of Columbia water system.
Our neglect of public health also contributes to spiraling health costs. We tend to address health care -- as a nation and as individuals -- after the sickness has taken hold, rather than addressing the cause through public health. Public health programs can help stop preventable disease and control dangerous behaviors. Take obesity, for example. Individuals should understand that they put their lives at risk with unhealthy behavior. But let's face it -- we live in a fast-food nation, and we need to take steps, like restoring physical-education programs in schools, that support the individual's ability to master his or her own health. Studies conducted by the Centers for Disease Control and Prevention have identified ''Programs That Work,'' which should be financed. It comes down to individual responsibility reinforced by national policy.
The public health system also needs to be brought up to date. The current public health tools were developed when the major threats to health were infectious diseases like malaria and tuberculosis. But now chronic diseases are the No. 1 killer in our country. We need to be concerned not just about pathogens but also about carcinogens.
Over the last three years, I have introduced legislation to increase investment in tracking and correlating environmental and health conditions. I have met with people from Long Island to Fallon, Nev., who want answers about cancer clusters in their communities. The data we have seen about lead and mercury contamination in our food and water suggest that the effects they have on the fetus and children may have contributed to the increasing number of children in special education with attention and learning disorders. We need more research to determine once and for all if increasing pollution in our communities and increasing rates of learning-related disabilities are cause and effect.
We should also be looking at sprawl -- talking about the way we design our neighborhoods and schools and about our shrinking supply of safe, usable outdoor space -- and how that contributes to asthma, stress and obesity. We should follow the example of the European Union and start testing the chemicals we use every day and not wait until we have a rash of birth defects or cancers on our hands before taking action. And we should look at factors in our society that lead to youth violence, substance abuse, depression and suicide and ultimately require insurance and treatment for mental health.
After Sept. 11, mental health was a significant factor in the health toll on our nation's first responders. And yet our mental health delivery system is underfinanced and unprepared.
Finally, as a society, we need greater emphasis on preventive care, an investment in people and their health that saves us money, because when families can't get preventive care, they often end up in the emergency room -- getting the most expensive care possible.
Expanding Coverage
All that we have learned in the last decade confirms that our goal should continue to be what every other industrialized nation has achieved -- health care that's always there for every citizen.
For the first time, this year a nonpartisan group dedicated to improving the nation's health, the Institute of Medicine, recommended that by 2010 everyone in the United States should have health insurance. Such a system would promote better overall health for individuals, families, communities and our nation by providing financial access for everyone to necessary, appropriate and effective health services.
It will, as I have been known to say, take the whole village to finance an affordable and accountable health system. Employers and individuals would share in its financing, and individuals would have to assume more responsibility for improving their own health and lifestyles. Private insurers and public programs would work together, playing complementary roles in ensuring that all Americans have the health care they need. Our society is already spending $35 billion a year to treat people who have no health insurance, and our economy loses $65 billion to $130 billion in productivity and other costs. We are already spending what it would cost if we reallocated those resources and required responsibility.
In the post 9/11 world, there is one more reason for universal coverage. The anthrax and ricin episodes, and the continuing threat posed by biological, chemical and radiological weapons, should make us painfully aware of the shortcomings of our fragmented system of health care. Can you imagine the aftermath of a bioterrorism attack, with thousands of people flooding emergency rooms and bureaucrats demanding proof of insurance coverage from each and every one? Those without coverage might not see a doctor until after they had infected others.
Insurance should be about sharing risk and responsibility -- pooling resources and risk to protect ourselves from the devastating cost of illness or injury. It should not be about further dividing us. Competition should reward health plans for quality and cost savings, not for how many bad risks they can exclude -- especially as we enter the genomic age, when all of us could have uninsurable risks written into our genes.
So achieving comprehensive health care reform is no simple feat, as I learned a decade ago. None of these ideas mean anything if the political will to ensure that they happen doesn't exist.
Some people believe that the only solution to our present cost explosion is to shift the cost and risk onto individuals in what is called ''consumer driven'' health care. Each consumer would have an individual health care account and would monitor his or her own spending. But instead of putting consumers in the driver's seat, it actually leaves consumers at the mercy of a broken market. This system shifts the costs, the risks and the burdens of disease onto the individuals who have the misfortune of being sick. Think about the times you have been sick or injured -- were you able under those circumstances to negotiate for the best price or shop for the best care? And instead of giving individuals, providers and payers incentives for better care, this cost-shifting approach actually causes individuals to delay or skip needed services, resulting in worse health and more expensive health needs later on.
Meanwhile, proposals like those for individual health insurance tax credits, without reforms for the individual insurance market, leave individuals in the lurch as well. We know that asthmatics can have their entire respiratory systems excluded from coverage. Individual insurance companies can increase your premium or limit coverage for factors like age, previous medical history or even flat feet. Those in the individual market cannot pool their risk with colleagues or other members of the group. The coverage you can get and the price you pay for it will reflect individual risk, and you simply don't receive many of the benefits of what we consider traditional insurance when people pool risks. So the proposal to give individuals tax credits to buy coverage in the individual market, without any rules of fair play, won't provide much help for Americans who need health care. In the same way, the recent Medicare bill, which seeks to privatize Medicare benefits, long a government guarantee, threatens to leave the ''bad risks'' without any affordable coverage. With the new genetic information at our disposal, that could mean any one of us could one day be denied health insurance.
When many of those who opposed the Health Security Act look back, they are still proud of their achievement in blocking our reform plan. The focus of that proposal was to cover everybody by enabling the healthier to pool the ''risk'' with others. The plan was to redirect what we currently pay for uninsured care into expanding health coverage.
We could make cosmetic changes to the system we currently have, but that would simply take what is already a Rube Goldberg contraption and make it larger and even more unwieldy. We could go the route many have advocated, putting the burden almost entirely on individuals, thereby creating a veritable nationwide health care casino in which you win or lose should illness strike you or someone in your family. Or we could decide to develop a new social contract for a new century premised on joint responsibility to prevent disease and provide those who need care access to it. This would not let us as individuals off the hook. In fact, joint responsibility demands accountability from patients, employers, payers and society as a whole.
What will we say about ourselves 10 years from today? If we finally act to reform what we know needs to change, we may take credit in building a health care system that covers everyone and improves the quality of all our lives. But if we continue to dither and disagree, divided by ideology and frozen into inaction by competing special interests, then we will share in the blame for the collapse of health care in America, where rising costs break the back of our economy and leave too many people without the medical attention they need.
The nexus of globalization, the revolution in medical technology and the seismic pressures imposed by the contradictions in our current health care system will force radical changes whether we choose them or not. We can do nothing, we can take incremental steps -- or we can implement wide-ranging reform.
To me, the case for action is clear. And as we work to develop long-term solutions, we can take steps now to help address the immediate problems we face. As Senator John Kerry has proposed, we should cover everyone living in poverty, and all children; allow people to buy into the federal employee health benefits program; and also help employers by reinsuring high-cost claims while assuming more of the costs from hard-pressed state and local governments.
We can pass real privacy legislation that will ensure that Americans continue to feel secure in the trust they place in others for their most intimate medical information. And we can realize the promise of savings through information technology and disease management by passing quality health legislation now.
If we do not fix the problems of the present, we are doomed to live with the consequences in the future. As someone who tried to promote comprehensive health care reform a decade ago and decided to push for incremental changes in the years since, I still believe America needs sensible, wide-ranging reform that leads to quality health care coverage available to all Americans at an affordable cost.
The present system is unsustainable. The only question is whether we will master the change or it will master us.
Copyright 2004 The New York Times Company |
