Revisiting American Health Policy: Why Change Comes so Hard

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Revisiting American Health Policy Why Change
Comes so Hard

• Steven A. Schroeder, MD
• The Flanigan Lecture
• July 31, 2008
• Kansas City

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Quick Poll

• How many think U.S. has best medical system?
• How many think our health system needs
  fundamental reform?
• How many are happy with your own medical care?
• How many think fundamental health care reform
  will come soon?
• How many think single payer financingMedicare
  for allis the best way to achieve universal
  coverage?
• How many are puzzled by why none of the major
  candidates for president endorsed a single payer
  approach?

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Performance of the U.S. Health Care System

• Health (outcomes)
• Costs
• Access
• Other important issues
• Explaining the quagmire

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Health Status of the United States

• Ranks 19-25 in usual indicators
• Examples and explanation

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Health Status United States vs. 29 Other OECD
Countries
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Health Status United States vs. 29 Other OECD
Countries (contd)
Data missing for six (6) countries
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Source Health, United States, 2001
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Some Good News

• US does much better for life expectancy after age
  65
• 2003 life expectancy data at all time high77.6
  years at birth
• Women 80.1, men 74.8
• White womengtblack womengtwhite mengtgtgtblack men
• Almost all the recent gains were in upper SES
  groups
• Much of those gains are from reduced tobacco use

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Proportions (Premature Mortality) (Premature
Mortality)
Determinants of Health
Social15
Genetic 30

• Genetic predisposition
• Behavioral patterns
• Environmental exposures
• Social circumstances
• Health care

Environment5
Health care 10
Behavior 40
Source McGinnis JM, Russo PG, Knickman, JR.
Health Affairs, April 2002.
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Behavioral Causes of Annual Deaths in the United
States, 2000
435
Number of deaths (thousands)


112
Sexual Alcohol Motor Guns
Drug Obesity/ Smoking Behavior
Vehicle
Induced Inactivity
Source Mokdad et al, JAMA 20042911238-1245
Mokdad et al JAMA. 2005 293293 Flegal
KM, Graubard BI, Williamson DF, Gail, MH. Excess
deaths associated with underweight, overweight,
and obesity. JAMA 20052931861-1867
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Tobacco Tipping Point?

• California 14 adult smoking prevalence
• National rates down to modern low of 19.2
• Northern California Kaiser Permanente down to 9
• Physician smoking rates around 1
• Proliferation of smoke-free areas
• Increasing stigmatization of smoking

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Tobacco and Obesity

• Characteristic Tobacco Obesity
• High prevalence X
  X
• Begin in youth X
  X
• 20th Century phenomenon X
  X
• Major health implications X X
• Heavy and influential industry promotion X
  X
• Inverse linkage to class X X
• Major regional variations X X
• Stigma X X
• Difficult to treat/clinician antipathy X
  X
• Definition is relative and debatable X
• Cessation not an option X
• No addictive component X
• Harmful at low doses X
• Behavior harms others X
• Extent of documented industry duplicity X
• History of successful litigation X
• Large cash settlements by industry X

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Policies to Combat Obesity

• Selective taxes and subsidies on foods
• Better labeling of foods and menus (esp. fast
  food restaurants)
• Restrictions on use of food stamps
• Counter-marketing, a la truth campaign
• Ban school vending of soft drinks
• Greater physical activity opportunities at work,
  school, and community
• Better treatment options

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Proportions (Premature Mortality) (Premature
Mortality)
Determinants of Health
Social15
Genetic 30

• Genetic predisposition
• Behavioral patterns
• Environmental exposures
• Social circumstances
• Health care

Environment5
Health care 10
Behavior 40
Source McGinnis JM, Russo PG, Knickman, JR.
Health Affairs, April 2002.
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Health StatusSummary

• Doing better
• But at bottom of developed world
• Major declines in heart disease (multiple
  reasons)
• Major opportunities for improvement in tobacco
  and obesity
• Cant improve without more attention to the poor
• Social causes very important
• Hard to improve through medical care alone

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Costs of Medical Care Were Still Number One!

• Now up to 16 of GDP
• Poor health value for the dollar
• Tendency to look for painless quick fixes
  (electronic medical record, pay for performance)
• Reluctance to take on the involved sectors
  (pharma, device and insurance industries,
  hospitals, doctors, unions)

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Percentage of Gross Domestic Product Spent on
Health Care in 2002
Source OECD Health Data
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Health Care Spending Per Capita in 2002Adjusted
for Differences in Cost of Living
2004 OECD Health Data
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Why Is U.S. Medical Care So Costly?

• Physician supply? No (but specialty very high)
• Fee for service payment valuations? Yes
• Health worker incomes? Yes
• Hospital supply/length of stay? No
• Proportion intensive care beds? Yes
• Rate of expensive procedures, and technology in
  general? Yes, in spades!

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Why Is U.S. Medical Care So Costly (Part 2)?

• Practice style variations? Yes
• Administrative costs? Yes
• Malpractice, including defensive medicine? Yes
• Aging population? Not really
• Higher prices for prescription drugs? A little
  bit
• Patient demand? Yes
• Lack of cost competition? Yes
• Low investment in IT? Maybe

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Why Does US Medical Cost Containment Fail?

• Americans (at least those who are insured) resist
  limited choices
• Power of industriesdevice manufacturers and drug
  companies
• Power of medical/hospital sectors
• Strong patient demand for more (e.g., alternative
  medicine)
• Surge of new technologies
• Political hot potato, and lack of accountability
  focus

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Why Not Let Costs Keep Rising?

• Opportunity costs
• Schools
• The environment
• Jobs and overseas competition (see General
  Motors)
• Other worthy causes
• Business resistance
• Operational costs
• Retiree costs
• Source of labor disputes
• Pressure on public programs (Medicare, Medicaid,
  County Hospitals)
• Increases the number of uninsured
• Biggest cause of personal bankruptcies

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Access to Health Care

• Insurance coverage the major barrier
• Gradual decline in employer coverage
• Geography, language, literacy, racial barriers
  also important
• Early hope for state reformgenerally blue
  states--as way to bypass federal gridlock
• Different salience for the two political parties,
  as revealed in the presidential primaries

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Why U.S. Tolerates Such a Large Number of
Uninsured? Explanations, Rationales and Myths
1. The numbers are exaggerated 2. Uninsurance
is often temporary 3. Many choose to be
uninsured 4. The uninsured get care anyway 5.
We cant afford to expand coverage 6. Government
is untrustworthy 7. American political system
prevents major reform 8. (Poor
under-represented politically) Schroeder SA.,
The medically uninsuredwill they always be with
us?, NEJM, 1996 3341130-1133.
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Went Without Needed Care Due to Costs, by Income





Access problems include Had a medical problem
but did not visit a doctor skipped a medical
test, treatment, or follow-up recommended by a
doctor or did not fill a prescription because of
cost Significant difference between below
average and above average income groups within
country at plt.05 Source Commonwealth Fund 2004
International Health Policy Survey
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Barriers to State Health Reform

• Employer mandate
• --free riders (Wal-Mart)
• --how high an assessment level?
• Individual mandates
• liberals and libertarians both dislike
• how subsidize low income workers?
• how enforce? (Obama/Clinton dispute)
• Isaacs SL and Schroeder, SA. California
  DreaminState Health Care Reform and the
  Prospects for National Change. NEJM, April 10,
  2008

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Barriers to State Health Reform (2)

• Costs
• -- Calif. 14b budget deficit sank its plan
• -- how raise the ? Cigarette tax and gambling
  are the most palatable
• Cost Control
• --prevention, IT, and care coordination as
  unproven (but safe) strategies
• --avoidance of provider jawboning

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Barriers to State Health Reform (3)

• Design of benefit package
• --too slim antagonizes special interests
• --too broad inflates costs
• --hard to arrive at Goldilocks solution
• Politics
• --Republicans see it as a Democratic issue
  (compare the two primaries, and recall Gov Romney
  fleeing the Mass. plan)

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Willingness of Healthier and Wealthier to
Subsidize Care for Sicker and Poorer is Weakening
Harris Survey question Do you agree? The higher
someones income is, the more he or she should
expect to pay in taxes to cover the cost of
people who are less well off and are heavy users
of medical services.
http//www.harrisinteractive.com/news/allnewsbydat
e.asp?NewsID1076
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The Catch 22 of Health Insurance Reform

• When the economy is prosperous and unemployment
  low, the middle class feels secure about health
  insurance
• When the economy goes bad and people lose jobs
  and health insurance, there is not enough money
  to pay for expanded coverage

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Other Major Issues

• Quality/safety of care
• Coordination of chronic illness care
• Long term care
• End of life care
• The work force
• --medical student debt corrodes values and
  influences career choices
• --erosion of primary care
• --future of nursing

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Why Are We Stuck?

• Doing better and feeling worse.
• America favors entrepreneurialism over solidarity
• America distrusts government solutions
• Our size and our political system makes change
  difficult
• Special interests are averse to losing status
  quo is everyones second choice
• The poor lack a political voice, compared with
  other nations
• Medicine lacks an organizing center

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Pathways to Resolution

• Economic depression mobilizes the middle class
• Charismatic president pushes legislation
• Business asks for help
• The profession mobilizes
• But demand for care will always exceed our
  ability to pay for it (also true for housing,
  clothes, etc.)

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Concluding Thoughts

• U. S. poor health status not correctable by
  better health care alone
• No easy solution to cost inflation will require
  multiple strategies, and will threaten a huge
  industry
• Increasing interest in comprehensive health care
  insurance coverage, but little consensus on how
  to get there
• Continued search for easy answers
• Health professions could and should be more active