Erin Miller

Last month, Tom Daschle asked Americans to lead community health care discussions in order to gather and share ideas on how to reform the American health care system. I wrote up a summary of one of those meetings.
If you’re interested in health reform — read on.

Holiday Health Care Discussion
23 December 2008
Seven people attended the health care community discussion.

Compelling Personal Stories
Story 1:
One story manifested the lack of a sufficient safety net for care of the elderly. One couple knows an elderly woman in a nursing home whose spouse is paying all of her medical bills. The spouse’s lawyer has suggested that he refuse payment and thereby disown his spouse in order to protect some of his assets for his own long-term care, but he will not do it because he believes its is a betrayal of his spouse.
Story 2:
The medical student that attended our discussion recently experienced a situation that provides a compelling example of the need for reform of the health care system. She was attending a clinic in an underserved neighborhood in Colorado when a 44 year-old, overweight, African American man came in. He had diabetes and high blood pressure, and the physician was glad to see him because this patient hadn’t been to the clinic in some time. The man was on many medications including a specialized medication to control his blood pressure. However, three months ago the patient had switched jobs and his insurance had lapsed. He hadn’t been taking any of his medications for three months. His blood sugar level was 450, substantially and dangerously above normal and his blood pressure was 260/120. They performed an EKG and sent the man to the Emergency Department. There, doctors determined that the patient had heart damage. The doctors observed him, admitted him, and performed several tests. The ED eventually discharged him but he didn’t feel well as he was walking through the parking lot, so he returned to the ED and arrested in the hospital. He was admitted to the ICU, and several days later his wife had to make the decision to withdraw life support. This medical student had seen the patient in a clinic, and one week later, the patient was dead. The story manifests the need for a better safety net, particularly for individuals between jobs. While all group members were aware of COBRA coverage, everyone agreed that it was prohibitively expensive. Policy makers must create an insurance program that is universal and continuous because stopping and starting coverage does not work, particularly for individuals with chronic diseases. Group members stated that insurance should not be connected to employment status.

Summary of Responses from Discussion Questions:
What does the group perceive as the biggest problem in the health system?
The group perceived the cost of health care services and the lack of transparency surrounding those costs as the largest problem with the health care system. Health care in the United States cost too much, especially considering the poor health status of many Americans. One group member suggested that health care in the United States was twice as expensive as health care in other developed countries in Europe, but Americans are not twice as healthy as Europeans from those countries. The lack of transparency in health care costs is a particular problem. Some tests cost $300 dollars if you do not have insurance and $30 dollars if you do have insurance, and group members were confused about how costs could vary so dramatically. Often patients cannot determine the cost of a prescription at a particular pharmacy until the prescription is run through their insurance. Policy makers should demand better transparency in the pricing of health care services. As businesses and individuals move toward more catastrophic insurance coverage, patients are gaining a greater interest in demanding lower priced health care services. However, without the necessary information to determine what the costs will be fore particular services, patients are forced to make economic and health decisions without sufficient information.
How do attendees choose a doctor or hospital? How can public policy promote quality health care providers?
Many participants relied on recommendations from other physicians, particularly the referring or primary care physician, to choose a doctor. Referring physicians often get feedback on the physicians they recommend. Some participants also used the internet to find information and reviews about physicians, though many participants recognized that some reviews, particularly if only a few reviews are given, can be biased. Group participants also mentioned that many patients are not able to choose their physicians because they have to go wherever their insurance is accepted, which can be particularly difficult with Medicaid. Public policy can promote quality health care providers through the creation of sound pay-for-performance (P4P) systems that use evidence-based standards. The creation of these standards will require a large body of comparative effectiveness research. Participants noted that it is important for pay-for-performance programs to be based on margin of improvement among patients and not the ability to hit particular targets, as some patient populations are sicker and more difficult to care for than others. A P4P program that uses specific targets can discourage physicians from taking difficult patients. Participants suggested that well-designed P4P programs combined with oversight from governing boards, which can revoke the licenses of particularly poor performers, were effective methods of improving quality in health care providers. One participant noted that publishing performance data is not a good method to improve quality in providers. Performance data can be difficult to understand and most patients are not able to make educated decisions even after reviewing the information.

Have attendees or their family members experienced difficulty paying medical bills?
No one in our group had been unable to pay their medical bills, though they recognized those bills as a substantial expense. Group member believed that they were rare and lucky to not have experienced difficult meeting those costs.

Would the group like the option of purchasing a public plan similar to Medicare?
All group members would like the option of purchasing a public plan like Medicare. However, group members recognized the difficulty of having such a plan “compete” against private companies. Private insurance companies would have to be regulated closely in order to prevent those companies from turning away those with high risks or pre-existing conditions, or only the sickest people in the country would be left wanting to purchase the public plan. This would force the costs of the public plan to be very high, further discouraging healthy people from joining the plan, therefore creating an adverse selection spiral. The option of a public plan would likely also require having an individual mandate, because with closely regulated private plans, and an expensive public plan, many healthy individuals would choose not to purchase any insurance, leaving only the sick and high cost individuals in the insurance pool.
Did group members know how much they or their employers paid for health insurance? What is an employer’s role in a reformed health care system?
All group members were aware of how much they or their employers pay for health insurance. However, the group recognized that many of the insurance documents and bills are written at very high reading levels and are often difficult to understand, even though all group members had education beyond the college level. Group members believed that people with less education would struggle to understand their insurance documents and health care bills. Group participants believed employers should have no role whatsoever in a revised health care system. Health insurance should not be tied to one’s job, because it makes it difficult to change jobs, creating job-lock and a loss of innovative potential, and it unnecessarily increases the fear surrounding the possibility of losing one’s job.
Preventive care
All participants were aware of the preventive services they should receive and had received the services listed. Public policy could help make those services available to more Americans by subsidizing their cost, because group members stated that cost was the primary reason some people may forgo preventive care.
Public policies to promote healthier lifestyles
1. Policies related to the public education system
a) Use the school system as a place to provide more preventive screenings to children (beyond hearing and vision). Perhaps weight, fitness, diabetes, and asthma screenings should also be delivered through the public school system.
b) Promote healthy, well-balanced meals at public schools.
c) Offer condoms and require comprehensive sex education in all public schools.
d) Increase requirements for time spent in physical education classes in public schools.
2. Community/Planning Policies
a) Promote public gardens – A pediatrician in the group noticed that children who had experience planting and cultivating vegetables were more likely to eat them.
b) Promote walking trails and green space.
c) Promote the planning of communities so that residences are within walking distance of public transportation, work places, and shops.
d) Evaluate the success of the Green Carts initiative in New York City and expand the initiative to other city centers if it is successful in encouraging inner-city residents to consume more fruits and vegetables.
3. Agriculture Policies
a) Pass the bill to update the WIC food packages to include fresh fruits and vegetables and less juice, which is very high calorie.
b) Either diminish subsidies on corn and sugar and other high-calorie foods, or add similar government subsidies to foods with higher nutritional value and fewer calories such as fruits and vegetables.
4. Mental Health Policies
a) Promote better mental health policies that decrease the stigma related to mental health treatment and make mental health treatment available to more people.