Sunday, July 12, 2009

Health Care Reform Letter

So, recently the Richmond Times-Dispatch (RTD) printed a letter to the editor which doubted the motivations of the current health care reform efforts in Washington.

I have a letter to the editor in reply, which I am going to send to the newspaper. I don't think they'll actually print it--it's long, and way to liberal for the RTD. So, I'm going to post it here so that I don't feel like I have wasted my entire day.


To the Editor;

I am writing in reply to a letter published July 6, 2009 in the Richmond Times Dispatch regarding the current administration’s health care proposal. In her letter, Ms. Kathy Dean raises a number of questions regarding health care reform legislation that is being considered. I would like a chance to address some of her points. I feel qualified to comment on this issue as I have spent my entire career working in medically underserved communities (urban and rural) where I have seen the harm and the challenges that result from the large number of uninsured and under-insured citizens of our country.

There is no doubt that the American health care system needs to be reformed. Currently, the United States spends nearly $7,421 per person on healthcare—equal to 16.2% of our nation’s GDP. They are projected to increase to 25% of GDP in 2025. These costs weigh heavily on businesses (employer-based family insurance policies cost employers an average of $12,680 yearly) and families (half of all personal bankruptcies are at least in part due to medical expenses, most of which involved people that had insurance when they first got sick). Despite these high costs, the health care we receive falls well short of desired goals. When assessed across 37 performance indicators, the United States healthcare system scored 65 out of a possible 100 points.

Despite Ms. Dean’s concern about the current legislation enacting “two separate health care systems—one for those with political clout and the rich who can afford to pay taxes on their gold-plated benefits, and one for everyone else”, we already have a healthcare that has dramatic inequalities. Currently, the division is between those who are insured and those who are not. Children who lack health insurance have decreased access to health maintenance services, including vaccinations, well-child check-ups, dental care and prescriptions. Adults who do not have insurance also receive less preventive care and typically suffer worse health outcomes if they get sick. Health inequalities are also notable among those Americans who have insurance: do you have a well-funded employer-supported plan that encourages check-ups and health maintenance, or are you limited to a plan that covers catastrophic illness or hospitalization and includes a sky-high deductible (which you had to choose to keep the cost affordable)? Let us not kid ourselves—the current system is terribly expensive, fails to provide adequate coverage for millions of Americans, and does not achieve its desired goals.

I think Ms. Dean raises some important questions; including whether there will be enough primary care providers to cover the new patients and who will determine the type of care patients receive. The answers to these questions will be determined by the legislation in question. Currently, it is clear that the administration recognizes the need to increase the number of primary care physicians in the United States to ensure that the workforce issue will be addressed. How to meet these needs, though, is still unclear and will not occur in the short-term. Medical students will need to be able to enter primary care careers while still being able to pay their medical school loans (which now average well over $150,000). This will require the current health care payment structure to be adjusted, and primary care physicians will need to be reimbursed for their work in a manner that fairly addresses the challenges of coordinating patient care, ensuring health maintenance, and dealing with needs of patients who present with multiple complicated medical problems. This will not be easy in light of the already-existing challenges to healthcare funding.

In terms of the types of care patients receive, this also has not been determined but as of now there has been no indication that any legislation coming out of Washington will involve rationing. In fact, the administration has made efforts to communicate that patients will be able to choose their physician and the patient/physician team will dictate care. No doubt that there will be some limits or conditions that will be enacted—prior authorizations, medical reviews, etc. However, these limits and conditions already exist in all commercial and government-funded health plans. There has been no indication of any dramatic shift from these models. The government will be funding research to help determine what treatments, medications, and interventions provide the most benefits and are most cost effective. However, there is no sign that the results of this research will dictate care or coverage.

Regarding illegal immigrants, there has been no sign that adults who immigrated here illegally will be covered under any government-provided options. Children who are present illegally may be covered under Medicaid and FAMIS under the Children’s Health Insurance Program (CHIP) legislation already enacted. Considering that this coverage provides for well-child visits and vaccines, which benefit the child while also protecting the community at large against communicable diseases, this coverage was politically viable. Adults are not likely to receive any such consideration, as much as I worry about the strain that will be placed on safety-net providers such as free clinics and emergency rooms once undiagnosed chronic illnesses such as high blood pressure, high cholesterol, and diabetes start to cause complications.

At this point, the public health insurance plan being discussed as part of the healthcare legislation is what appears to be causing the most discomfort among those who oppose the idea. According to polling by Health Care for America Now! (HCAN) the idea of a public health insurance plan is well received by a majority of Americans. This plan would work within the current marketplace to provide an option beyond the commercial insurance plans. This plan will allow for more equitable enrollment of people who are healthy and require relatively few health care interventions and those who require more health care resources. Currently, a disproportionately large number of patients who require more health care are enrolled in public plans (Medicare and Medicaid) while those who are less-frequent users are disproportionately enrolled in private plans. If a public plan enrolled Americans from both the high-use and the low-use groups then the costs of premiums would be lowered and more affordable. This option could also make use of the fact that government-run programs have historically had much lower overhead costs for administration purposes (around 5% or so for public plans) as compared to for-profit commercial plans (nearly 30%). In addition, a public plan could be structured to emphasize health maintenance and health-promotion (including consideration of ideas such as the patient-centered medical home) that will prevent illness while also increasing the appeal of primary care medical careers. The public plan could also emphasize health interventions that work and that are cost-effective, as opposed to promoting new and flashy medications and technologies that have little to no additional benefits but that are dramatically more expensive.

It is a shame that Ms. Dean questions whether party affiliation will affect health care, and that she invokes President Obama’s position on abortion to question the motivation and results of these health care reforms. This issue is too serious, will have too many long-term repercussions, and will affect too many people to get caught up in unfounded rumors. There is no call in the current plan for a single-payer national health plan (much to the distress of many who would support it and who can show evidence that such programs improve outcomes and reduce costs)—if the public health insurance plan that is being discussed is not viable, then it will fail in the marketplace. There has been no indication that party affiliation will have anything to do with the coverage one will receive. By developing a health care reform plan that intends to provide affordable coverage to everyone, the current administration is seeking to provide care to the most vulnerable members of our society while also making care available to everyone else: the working poor who represent a large proportion of the uninsured; the self-employed and small businesses who have to choose between paying exorbitant premiums to commercial plans or reduce or eliminate coverage for themselves and their employees; large corporations who face a built-in hurdle compared to other developed nations because American companies have to pay high costs for employee’s health insurance while carmakers in other countries do not have to face this challenge. In short, the current health care reform efforts present a chance to provide meaningful and valuable care for all while still allowing for individual plan choice and reducing costs.

There is no question that our current healthcare system is unsustainable. We pay far too much for much too little, and too many are left uncovered. We need to take full advantage of this opportunity and develop a long-lasting, improved system. This legislation will dictate healthcare in the United States for decades, and it needs to include coverage that would be available to everyone and that will focus on health maintenance, treatments that provide health benefits and are cost-effective, and that will be sustainable long into the future.


So, that's my perspective. I'm interested in any comments or thoughts, so please feel free to post some if you would like to.


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