Michael Moore’s film “Sicko” uses social commentary to hold health care in the United States up to shame. Though Moore neither adequately diagnoses nor prescribes treatment for the patient he observes—our health care system—his film prods viewers into thinking seriously about his subject. This article considers both the dark and the bright sides of health care with a view toward future improvement.
On the dark side, the system as a whole is broken, not just the financial and insurance aspects of health care. The way diagnoses are made and care is delivered is actually a non-system, a chaos composed of fragmented services and partial treatments. It accidentally kills 90,000 people a year through medical error—death by health care. The number of serious injuries, dangerous side effects and deaths from over-the-counter and prescription drugs alone nearly tripled between 1998 and 2005.
Health care in the United States ranks as the world’s costliest at $2.2 trillion annually (17 percent of G.D.P. compared with 10 percent in other developed nations). Health insurance premiums continue to rise, with increases outpacing inflation. According to a September 2007 report by the Kaiser Family Foundation, a research organization that tracks the cost of health insurance, this year’s average premium for a family of four was $12,106, of which workers paid $3,281 on average; for a single person it was $4,479, of which workers paid $694. The portion that families and single people pay has nearly doubled since 2001. Rising premiums make insurance less affordable even for businesses and working people. And the number of people without health insurance—47 million—is growing. Already serious problems of accessibility and equity grow with it.
Studies by nonpartisan agencies show that Americans seldom get the world’s best care for their expenditure. A few years ago the World Health Organization ranked the health care of 191 countries and placed the United States 37th, on a par with developing, not advanced, countries. A New York Times editorial on Aug. 12 noted that when the Commonwealth Fund looked at quality and access to care in the United States and in five other nations (Australia, Canada, Germany, New Zealand and the United Kingdom), it judged the United States number one for providing the right clinical care but last on a number of other measures, including treatment of the chronically ill and frequent medical deaths.
On the bright side, health care in the United States has access to the most advanced medical technology in the world, technology that our best hospitals have rapidly assimilated and are already using to benefit patients. The United States also operates world-class medical schools and hospitals. And some insurers have learned from their experience in the early years of managed care to allow prevention and intervention and to give consumers a choice of physicians. Currently, health care includes conceptual and institutional developments that can lead to substantial improvements.
Crossing the Quality Chasm
Since 1996 the Institute of Medicine has focused on understanding and addressing the quality problem. That year it launched a series of studies aimed at “crossing the quality chasm.” The project first documented the nation’s overall quality problem, concluding that “the burden of harm conveyed by the collective impact of all our health care quality problems is staggering.” Second, it published two major documents, To Err Is Human: Building a Safer Health System (1999), on medical error, and Crossing the Quality Chasm: A New Health System for the 21st Century (2001). Both emphasized that reform around the margins is inadequate to address systemic ills and prescribed comprehensive change through a new transformational vision of what needs to be done. Now in its third phase, the project is making its recommendations operational.
It has developed a model from six stated aims for quality care: care must be safe, effective, patient-centered, timely, efficient and equitable. The model defines quality in measurable terms as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” And it provides new rules for client-professional relationships.
The institute has studied many aspects of quality—from primary care and the treatment of chronic conditions to delivery of care, nursing, technology and so on—and has identified priority areas for action. In 2005 it produced Improving the Quality of Health Care for Mental and Substance-Use Conditions, which advocated incorporating care for mental health and substance use conditions into overall health care.
So we know a great deal, but we need to implement what we know and figure out how to pay for it. Today, eight years after an institute study called for quality care for cancer (1999), research shows that uninsured cancer patients tend to be diagnosed at an advanced and less curable stage of cancer than insured patients; many families, even those with insurance, cannot meet the high costs of treatment because of limited benefits. Quality, delivery, cost, coverage, equity, policy, the doctor-patient relationship, effectiveness—each aspect affects the other. The non-system cannot be fixed piecemeal, but rather by developing a true system. Those of us who work with health care systems and delivery recognize that financial reform of health care cannot focus on the fragmented non-system any more than reform around the margins of health care can improve quality of care.
Money, Health and Government
Most Americans receive health care through employer-based insurance plans—a combination of H.M.O.’s and out-of-plan physicians. For the indigent, the government offers Medicaid, for seniors Medicare. The Americans left out of this system are the 47 million “uninsured,” a group that includes workers who have opted out of their employers’ insurance plan, persons with jobs but no insurance benefits and persons without jobs. The number of uninsured also includes children without coverage.
Because of the increasing cost of employer-based insurance, employers struggle with large liabilities; and health care coverage has become a chief point of negotiation in labor-management contracts. The recent agreement reached between General Motors and the United Auto Workers, for example, hinged on providing an alternative, a trust called a “voluntary employee benefit association” (VEBA), which includes the union’s participation and will secure the benefits of retirees and every hourly worker now at GM for 80 years, while allowing GM to strengthen its manufacturing competitiveness here and globally.
Some politicians in the United States have needlessly whipped up anxiety by associating any prospect for a more unified approach to health care with “socialized medicine.” If health and systems of care led the conversation, however, we might see the money problem differently and be better able to solve it. Rather than throwing good money after bad at the current non-system—including good money from joint employer- and government-sponsored plans—we must pay attention to new models of care, some emerging from state and federal government and some from healthcare professionals, which deliver more efficient and effective care. Doing this would help place universal coverage in perspective as a means, not an end. We need a good system of care with reasonable access. As the New York Times editors put it, “All other major industrialized nations provide universal health coverage, and most of them have comprehensive benefit packages with no cost-sharing by the patients.” The United States is the lone exception.
Bipartisan support is harder to obtain today than it was a decade ago, but some states have attained such support on health care. In California, a field poll in January 2007 revealed that 81 percent of the voters thought “it should be public policy that government guarantee that all Californians have access to affordable health care insurance or other health care coverage,” that is, universal health care coverage. Since various drafts of a health care reform plan include universal access to health care as the goal, California’s citizens will likely benefit no matter which proposal prevails.
Working with Democrats, Republican Governor Arnold Schwarzenegger has contributed many ideas to the process. Recently, however, Assembly Bill 8, the plan as it currently stands, faces the governor’s veto. The Associated Press quoted him as saying, “First and foremost, AB8 does not cover everyone…. Any reform that leaves millions without health insurance and fails to address our dangerously overcrowded emergency rooms simply maintains a broken system.” When Schwarzenegger judged that the proposal put too great a financial burden on businesses, he called for a special session of the legislature to address the issue. California is not giving up; it simply has to work it all out.
Last year the Massachusetts legislature and governor worked out a plan to ensure that everyone in the state has health insurance coverage. The idea was to improve the quality of care, reduce the cost and remove barriers to access. On April 12, 2006, health care reform became law. Provisions in the bill aimed at achieving nearly universal health insurance coverage, but also maintained a strong safety net, which has historically distinguished the state.
The plan could be nicknamed the “shared responsibility” plan because it asks government, employers, insurers and citizens all to do their part to expand health coverage and quality of care. A chief feature of the plan is the “Commonwealth Health Care Connector,” with its own advisory board and Web page that connects individuals and small businesses with health insurance products. The connector allows for portability (coverage travels as individuals move from job to job) and permits more than one employer to contribute to an employee’s health insurance premium. The plan allows H.M.O.’s to offer coverage linked to health savings accounts, reducing costs for those who enroll. The plan has also created a subsidized insurance program called the Commonwealth Care Health Insurance Program for individuals who earn less than 300 percent of the federal poverty level and are ineligible for the state Medicaid program. Premiums for this program will be set on a sliding scale based on household income, and no deductible will be required. The bill has expanded eligibility for employee participation in the current Insurance Partnership program from 200 percent to 300 percent of the poverty level, providing another option for small businesses who want to offer health care to their employees.
The bill shifted significant federal resources from supporting individual hospitals to funding health insurance coverage for uninsured individuals, and requires a lifetime spending ceiling for waiver services. It also created a “fair share contribution” (approximately $295 per full-time employee per year) to be paid by employers who do not provide health insurance for their employees. And the bill required that, as of July 1, 2007, all residents of the Commonwealth must obtain health insurance coverage. Individuals for whom there are no affordable products available are not penalized for not having insurance coverage.
A year into the Massachusetts plan, Nancy Turnbull, a dean at the Harvard School of Public Health, noted that 170,000 people have insurance today who otherwise would not. But universal health care, while an important achievement, will not solve the problem of quality.
It is too early to assess the effectiveness of these state initiatives, though they do show boldness and creativity and hold promise. They also offer some parallels with successful programs elsewhere, notably in Holland, which implemented a plan in 2006 requiring individuals to buy insurance or pay a penalty and requiring insurers to offer coverage to all comers. The difference between the Dutch plan and the plans of Massachusetts and California is that Holland does not require employers to offer health coverage.
Cost—whether one looks at insurance, government expenditures, equity, employer contributions or health care quality—remains a major issue. We Americans are well on our way to spending 20 percent of G.D.P., $1 of every $5, on health care. Without universal health care, such high costs will only increase the gap between Americans who can pay for what they need and Americans who cannot. As we pursue the best possible health for all Americans, we must find ways to reduce all related costs. That entails redesigning the whole system. The current broken system will only drive up costs. Yet an undertow seems to pull Americans down so that they resist changes in the financing of health care.
Toward a New Health Care System
Having worked during the 1990s at understanding multiple systems of care and how they do or do not intersect well, I have come to see that health and health care are the focus; they give the proper perspective. Public policy cannot be focused on financing, because we will not get the financing right until we put research and time into developing systems of care in which patient outcomes are measured and found to be better.
New systems of care are emerging in several still-developing models that could help improve American health care, because they focus on health and health care itself and take a new, pragmatic approach to the administration of care from the ground up. What characterizes the new models is the design and implementation of a system that is patient-centered, not doctor-visit or hospital-centered, yet that still links a patient to a primary-care practitioner.
The new models draw on medical technology and centralized records (available even in the home) so that telephone and Internet communication help build a continuum of relationship and emphasize wellness and prevention, as well as medical treatment of illness. The models cultivate different perspectives, gained through the use of “coaches” or care managers, in person or by electronic means, and advance the patient’s ability to manage his or her health. And they bring all these features together with social support.
Instead of rewarding professionals for tests, treatments and number of visits because of illness or chronic conditions, as is currently the case, these models reward medical and health professionals financially for producing health and preventing illness (as patients quit smoking, lower their cholesterol, need fewer or no hospital stays, lose weight, lower blood pressure, control and monitor diabetes, etc.). In sum, these emerging models centralize health care in the patient and treat the patient as a whole human person, allowing the patient to take charge more effectively of his or her own health.
What is beginning to dawn in the mind of the average American citizen, and may characterize health care in the 21st century, is the patient-centered and socially collaborative design in which care is based upon continuous healing relationships, not visits. The patient is the source of control, not the health professional. Knowledge is shared and information flows freely, and decisions are based on solid evidence.