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Health-care reform: The risk of doing nothing

The challenges facing health care are well understood, but many of the specific remedies remain in dispute. Regardless of one’s views, health-care reform is required because we can no longer afford the rapidly rising trajectory of expenditures. In addition, we need reform in order to provide patients with care that, according to the Institute of Medicine (IOM) is “safe, timely, equitable, efficient, effective and patient-centered.”

Currently our health-care system often does not meet those goals. We are the only developed country without universal health-care coverage, and as such have a moral imperative to eliminate inequities in our current system by ensuring health-care coverage for millions of uninsured. We are the most expensive health-care system in the world, spending 16 percent to 17 percent of our GDP on health care — which is 30 percent to 100 percent more (on a percentage of GDP basis) than other developed countries, and yet when compared to other developed countries we perform poorly on specific outcome measures such as infant mortality and longevity. We have an inefficient system, with reports that approximately 30 percent of the health-care spending goes for ineffective, redundant or inappropriate care. We need to reinvigorate efforts to improve patient safety. And we must address the looming financial threat to Medicare, at least part of which is the result of wasteful spending on unnecessary care and fraud.

A sometimes unseemly process
During the past six months, we have witnessed the tortured and sometimes unseemly process of health-care reform. Even now the outcome remains uncertain. Considerable confusion still exists among the public regarding which specific proposals are included in the legislation and how each of the proposals will affect individuals. Contributing to the confusion is the erroneous impression that there is a single proposal being debated — the Senate Finance Committee’s bill (Baucus bill).

In reality, the path to final congressional approval involves clearing several hurdles. Three House committees have agreed on a common bill, which still must be voted on by the full House; two Senate bills (including the Baucus bill) were approved by their respective committees and now must be reconciled to one bill that the full Senate must approve. If the House and Senate pass their respective bills, then a joint conference committee must reconcile a final draft that again must be approved by the full House and Senate. The Baucus bill or something similar, however, appears to have the best chance of receiving the 60 votes required to avoid a filibuster and allow passage in the Senate.

The public is not alone in struggling to follow the process and understand the many complex and complicated issues: A deeply divided Congress has spent much of this year grappling with a formidable range of controversial issues and now faces a treacherous and uncertain path — which, if successful, would lead to a final vote in both the House and Senate.

Two complementary strategies
Although no single piece of legislation can resolve all the problems in our current health-care system, successful reform requires Congress to acknowledge the magnitude and the urgency of the problems by simultaneously adopting two different but complementary strategies: 1) identify specific proposals that can be enacted within a year and 2) develop a plan for oversight and implementation of proposed changes that will require a longer time frame.

An example of the first category is elimination of the exclusion for preexisting conditions. In the Baucus bill, individuals would be eligible to obtain health insurance without restriction for preexisting conditions one year after passage of the bill.

Efforts to reform our health-care system, however, will not be successful unless we develop an ongoing plan for implementing those proposals that will require a longer time frame as well as develop a plan for comprehensive reform and establish a mechanism and roadmap to ensure that the most difficult and contentious issues undergo further review.

Proposals for continued reform
Unfortunately, the current proposals only address a limited number of the problems in our health-care system. There are recommendations in the current reform proposals for creation of a Medicare commission — either the current Medical Payment Advisory Commission (Med PAC) or similarly constituted group of experts — which would be responsible for developing policies for continued reform. For example: changing provider compensation so that payment is based on outcomes rather than fee-for-service piecemeal work, and using comparative effectiveness analysis to reduce the estimated one third of health-care services considered to provide little or no benefit.

Although the current reform legislation leaves a number of problems unresolved, it does remove some of the most egregious inequities and starts the necessary process of overhauling our health-care system. For that reason alone we should support it. To do nothing would be unconscionable.

Robert Knopp, a physician and medical educator, lives in St. Paul.

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Comments (5)

  1. Submitted by Greg Kapphahn on 10/20/2009 - 09:15 am.

    Thanks for a straightforward analysis of where we are in this process and what still needs to happen. Your lack of hyperbole was like a breath of fresh air.

    Let us all hope and pray that at the end of this very human and imperfect enterprise, something useful for the entire populace of these United States will be the result, even if, in the end, it’s only preliminary.

  2. Submitted by Carrie Johnson on 10/20/2009 - 09:22 am.

    “In reality, the path to final congressional approval involves clearing several hurdles…”

    Without copying the entire paragraph, it is a shame that the current path is so winding to get to the results we need.

    It’s a shame we might have to wait until 2014 to see this reform take place. We recently addressed that very issue on our website at http://cli.gs/MddhBm

  3. Submitted by Bernice Vetsch on 10/20/2009 - 03:27 pm.

    Payment based on outcomes rather than procedures performed?

    That could mean bankruptcy for an oncologist who probably doesn’t meet a lot of his/her patients until they are terminally ill.

    Or for a geriatric specialist, many of whose patients suffer from a range of chronic conditions; for example one person with heart disease, diabetes, obesity and arthritis complicated by emphesema.

    Perhaps “outcome” needs to be redefined. The current fee-per-procedure and/or office visit certainly has proved to be expensive and lacking in the ability to spend more time with those who need more.

  4. Submitted by Tom Anderson on 10/20/2009 - 07:38 pm.

    I must agree with Ms. Vetsch about the “outcome based” payments. Also, it seems a tad unnerving that over one trillion dollars will “start the process”…

  5. Submitted by john scope on 10/21/2009 - 10:28 pm.

    As the old saying goes, the health care proposals before Congress are just “re-arranging the deck chairs on the Titanic”.Republicans and Democrats alike tacitly agreed to create a smokescreen, a straw man argument, that single payer can only mean a government run health care system and then they took their respective opposing positions on the issue. Try asking liberal, conservative and independent voters how many would support a single payer system if it was not government run.

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