Personal Perspective

Call for a slower approach to health care reform

David G. Nathan

Dana-Farber Cancer Institute and Children’s Hospital, Boston, Massachusetts, USA. E-mail: david_nathan@dfci.harvard.edu.

First published September 10, 2009

Health care in the United States is in shambles. We justifiably boast of our prowess in high technology, but our measurable standard health care results are among the poorest in the developed world, well below those of Western Europe. Our costs per citizen are almost twice those of Western Europe and remain on a ruinous rising curve. We are not providing adequate primary and preventive care to our large pool of uninsured and poor citizens, who get unnecessarily sick and cost much more to treat in the long run. We are vastly overtreating and overtesting millions of patients, particularly the elderly and those in the last few months of life. Insurance premiums are confiscatory but unnoticed by those who have employer- or government-based insurance. The premiums are destroying our worldwide competitiveness. Smoking, the cause of 30 percent of cancer and much of cardiopulmonary disease, is still a menace, and we have allowed the soft drink industry and the corn lobby through a supine Department of Agriculture to poison our public school meals program with corn products enough to induce an epidemic of obesity and diabetes — all preventable. It seems ridiculous on the surface to propose an expansion of health care services unless we totally change the models of health care delivery and disease prevention that have brought us to this precipice.

Unfortunately, any proposed change of our bankrupt system is a third rail for politicians. Drug companies need profits to create new drugs, but they usually lose money when new drugs are developed because the new drugs fail so often. So they charge what the market will bear for successful drugs and make copycat drugs that they directly market to unsophisticated patients and gullible busy doctors. The executives of insurance and drug companies enjoy huge compensation and are focused on their quarterly stock appraisals instead of their mission. Doctors who do procedures are often adherents of independent fee-for-service medicine — particularly if they own the services. Hospitals charge better-paying insurers to make up for inadequate payers. Great academic hospitals are forced to play every legal billing trick in the accounting playbook in order to remain in the black for clinical services so that they can absorb inevitable losses in biomedical research and teaching. The elderly may deride government, but they are equally prone to shout “Don’t touch my Medicare.” All of this (and there is much more) amounts to a witches’ brew of political hazards for those in the White House and Congress who must find a way out of the mess and still remain in office.

To his credit, President Obama has decided to champion reform, but his timing could not be worse. We are facing a $9 trillion accounts deficit at the end of the next decade. No one knows whether lenders will be available if we accumulate such a huge deficit. The alternative is rampant inflation. Even if the health care stakeholders were of common mind (which they are not), this is a dangerous moment in which to begin an overhaul of a very large fraction of the economy, the consumers and providers of which are galloping off in all directions. The President is right, of course, when he tells the public that if we do not make necessary changes, the entire system may be imperiled, but he soft-soaps voters when he tells them that reform will be painless, provide portability, and ban rejection from preexisting conditions and cancellations. No one will become bankrupt from illness, nor be required to change insurance policies or physicians. Like Bush, he asks for no sacrifice from average Americans. But unlike Bush, he assigns replacement for every deficit-producing increase in a broken budget to increments in taxes on the rich. He doesn’t seem to notice that the ranks of the rich are becoming depleted as incomes decline. He speaks vaguely about heightened efficiency of care and implies that electronic records represent a near-magical path to solvency but provides no hard data to support his sunny optimism; nor does he seem to recognize that electronic records are hugely expensive to install, difficult to learn, and slowly accepted by most current physician. He lauds the Cleveland and Mayo Clinics, but they are referral-based specialty clinics. The inner-city or rural poor do not go there.

The facts are that we cannot achieve a cost-conscious, efficient health care system that reaches the poor as well as the affluent and preserves our excellence in discovery and technology without undertaking a massive change in our entire medical care culture. We must build a much stronger primary care system in which nurses — backed by experienced physicians-— take far more responsibility. Group practice must dominate medical care, and salaries rather than fee-for-service should be the predominant method of practitioner reimbursement. We need coherent regional medical care in which patients are referred to established centers for highly technical procedures akin to the WAMI (Washington, Alaska, Montana, Idaho) program undertaken by the University of Washington. Reimbursement by insurers, whether public or private, must be reasonable, but it must be tightly managed to prevent the current raid on the US Treasury and private insurance policies. Accordingly, we need much tougher insurance rules. Every insurance policy other than health insurance has a deductible. Absent “skin in the game,” insured patients will willingly undergo one useless expensive test after another. If we get to a single nonprofit payer (the executives of which eschew lucullan salaries), we will have to determine the deductible that must be paid by any covered family or individual.

Achievement of these necessary changes will take time. President Obama is a brilliant man and a great educator. He should teach the public about the need for and details of reasonable health care reform while he straightens out the economy. When Americans are clearly going back to work and deficits are beginning to shrink, morale will rise, and he can start us on the long, bumpy road to a decent health care system. I realize, of course, that Democrats, the party of health care reform, are in a precarious political position because of the failures of the previous administration and may not have enough votes to push through any plan after the elections of 2010. But we are talking about an enormous and hugely costly program with a profound impact on our economy and, indeed, our entire future. We simply have to get it right if we are to take it on at all.