What Does Health Care "Reform" Mean? How Soon Can We Get There? Part 1

Forces calling for Healthcare Reform Now are gaining momentum. I share their sense of urgency -- assuming that they are talking about the "reforms" needed to create an effective, affordable, patient-centered health care system. But if by "reform," they simply mean "universal coverage," I have to disagree.

Granted, giving every American a piece of paper labeled "health insurance" will bail out a health insurance industry desperate for customers. And it will help drug-makers, device-makers, and medical-equipment makers. But it will not solve patients' problems. What Americans need is not health insurance, but effective health care.

A stunner of a story in yesterday's Washington Post makes it clear that today we are pouring money into a health care system that does more for the health care industry than it does for patients.

"We're not getting what we pay for," Denis Cortese, president and chief executive of the Mayo Clinic, told the Post's Ceci Connolly. "It's just that simple."

"Our health-care system is fraught with waste," added Gary Kaplan, chairman of Seattle's cutting-edge Virginia Mason Medical Center. According to Kaplan: "As much as half of the $2.3 trillion spent today does nothing to improve health."

"Not only is American health care inefficient and wasteful," declared Kaiser Permanente chief executive George Halvorson, "much of it is dangerous."

This is a startling indictment, and one that health care reformers should heed.

"There is a broad consensus on what should be done," writes Connolly. The system needs structural reforms which include "realigning financial incentives, coordinating care, researching what treatments work best...and most daunting but perhaps most important, saying no to expensive, unproven therapies."

Therapies that have not been fully tested harm tens of thousands of Americans each year. Consider this: 10 percent of all drugs approved by the FDA from 1975 to 1999 were later withdrawn from the market or "black-labeled" to warn of risks.

2009: Fund Medicaid, Expand SCHIP and Begin Making Hard Decisions

What can Congress do next year? First, legislators should expand SCHIP and provide additional funding for Medicaid so that more low-income families are covered.

But this does not mean that we should throw good money after bad by paying healthcare insurers billions of dollars to shove millions of uninsured and underinsured middle-class Americans into an over-priced, broken system. The insurance industry has said that it wants reform that requires that every American purchase insurance -- without making any promises about what it will charge customers who come with "pre-existing conditions."

If we do that, we will be stuck with a larger version of the mess we have today. And at that point, it will be all but impossible to make the structural changes that we need to protect patients. By delivering captive customers to for-profit insurers, drug-makers, device-makers , equipment makers and for-profit hospitals, we fund the lobbyists who will fight meaningful reform.

But there are steps that Congress can take next year to make effective care more affordable for everyone:

• Allow drugs to be imported from Canada, putting pressure on pharmaceutical prices. Simultaneously, Congress should consider legislation that would let Medicare use its clout to negotiate for discounts on drugs and devices which now account for fully 16 percent of the nation's health care bill. Private insurers would follow Medicare's example, and before long everyone would be paying less.

• Insist on unbiased medical evidence showing that a new product or procedure is more effective than a less expensive product or service already on the market. Today, the FDA requires only that a sponsor show that its new entry is better than a placebo -- i.e. that it is better than nothing. The FDA also should demand that manufacturers follow through on monitoring the long-term safety of a product after it is on the market. Finally, Medicare should require similar evidence before agreeing to cover a product or procedure. (Today, private insurers follow Medicare's cues when deciding what to cover, so this would help keep a lid on insurance premiums in the private sector as well.)

• Raise the fees Medicare pays primary care doctors, geriatricians, family doctors, and palliative care specialists for services that can reduce the need for expensive, high-tech medicine. At the same time, trim the fees Medicare pays for services of marginal value. We already have identified a wide range of products and services that provide little benefit for many patients -- and in some cases, do more harm than good. They range from cholesterol-lowering drugs that can lead to painful side effects for patients over 65 to unnecessary angioplasties (in cases where medication and exercise would be more effective); MRIs for back pain (when physical therapy would provide much better value for our dollars); and PSA testing and treatment for early-stage prostate cancer, ( which the National Cancer Institute no longer recommends for average-risk men over 50.)
Private insurers model their reimbursements on Medicare's fee schedule; once again, Medicare reform would reduce costs for everyone.

These are just a few of the reforms that Congress could put in place next year to make healthcare safer while simultaneously putting a brake on runaway health care inflation.

Why Universal Coverage Will Take Time

If reformers want sustainable, patient-centered healthcare, Congress must squeeze the hazardous waste out of the system -- and this will require taking on a for-profit health care industry that is reaping billions from the status quo.

We have no choice. The experts agree that between one-third and one-half of the $2.2 trillion we now spend on health care is squandered on ineffective, sometimes unwanted procedures, unnecessary hospitalizations, and over-priced, drugs and devices that are no better than the less expensive products that they are trying to replace. And this isn't just a waste of resources.

Any medical treatment, no matter how simple, carries some risk. Whenever a patient undergoes an unnecessary procedure he or she is, by definition, exposed to risk without benefit. In the worst-case scenario, an unnecessary hospitalization can result in a fatal medication mix-up or a gruesome surgical site infection. Each year, as Shannon Brownlee reports in Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, an estimated 30,000 Americans are killed by what doctors call "iatrogenic disease" -- disease caused, inadvertently, by medical care. Thousands of others are seriously injured.

We are saddled with a health care system designed to put the desires of the health care industry above the needs of patients. David Mechanic sums up the challenge we face in The Truth About Health Care: Why Reform Is Not Working in America: "At some point we as a nation will have to decide whether we wish to design our health care system primarily to satisfy those who profit from it or to protect the health and welfare of all Americans."

"Speed is of the Essence"

Nevertheless, those beating the drum for Universal Coverage Now seem to be winning the debate in many circles. The most recent issue of the New England Journal of Medicine offers an example in an article titled: "The Lessons of Success -- Revisiting the Medicare Story."

The authors, Dr. David Blumenthal and James Marone, not only "revisit" the story of how Lyndon Johnson turned Medicare proposals into law; I am afraid that they also revise history: Blumenthal and Marone argue that LBJ fast-tracked Medicare through Congress and that Obama should follow his model: "Speed is of the essence."

But the truth is that before LBJ became President, John F. Kennedy had worked on Medicare for 18 months. JFK began the fight in January of 1961. And by "the end of the 1961 session of Congress, the tempo of the Kennedy administration's Medicare campaign began to pick up," reports Peter A. Corning in The Evolution of Medicare -- From Idea to Law, a book Corning wrote while memories were still fresh in 1969. A few weeks later, Health, Education and Welfare Secretary Ribicoff publicly pledged "a great fight across the land" for Medicare. Medicare was a featured topic around the country in late October at a series of 14 White House-sponsored regional conferences."

Gallup polls showed public support running as high as 69 percent. "By far the most important cause for optimism during the spring of 1962, though, was the progress of behind-the-scenes negotiations between administration strategists and the members of the Ways and Means Committee," Corning writes.

"The climax of the public debate came in the spring of 1962. On Sunday, May 20, President Kennedy spoke to a crowd of nearly 20,000 elderly people in New York's Madison Square Garden, while other administration officials addressed similar rallies in 45 cities. The President's speech was broadcast live over three television networks to an estimated home audience of 20 million persons. Two days later, the AMA's Dr. Edward Annis replied in a network speech broadcast from the same platform used by the President, but with the Garden auditorium dramatically empty, to symbolize the AMA's "underdog" stance." Estimates suggested that 30 million people watched Annis' speech.

Two months later, the full Senate voted on the bill, and Medicare was defeated 52-48. Once again the AMA had steamrolled the opposition. But Kenney had laid the groundwork for passage, both in Congress, where many liberal Republicans now supported the idea, and throughout the country.

Surprisingly, Blumenthal and Marone do not mention Kennedy's work in their NEJM article. This is because they are intent on sending a political message to President-elect Obama "speed is essential. Johnson knew this in his bones. The savvy health advisor will turn to the president-elect the day after the election and tell him, ' Hurry up, we're almost out of time for health reform.'"

To reinforce there message, the article's authors must pretend that LBJ drove Medicare through Congress single handedly, full-speed ahead., in a year or so.

In fact, LBJ inherited a Medicare campaign that was not dead, only dormant.
Following Kennedy's assassination, LBJ built on the work that JFK had done, using grassroots support for a martyred president to make his case.

But it wouldn't be easy, even for LBJ. In November of 1963, LBJ began work on Medicare; in July of 1965. Johnson finally rammed his bill through Congress. This was neither a quick nor an easy process. And it was hardly an example of gentlemanly "bipartisan compromise."

Johnson threatened everyone -- Democrats and Republicans alike. LBJ had spent much of his adult life in Congress. He knew where the bodies were buried, and he was capable of being absolutely ruthless. Moreover, in contrast to Obama, LBJ enjoyed a landslide victory in 1964 -- the largest plurality in U.S. history. He had the wind at his back.

Even then, it took him 19 months to achieve his goal -- 19 months on top of the 18 months that JFK already had invested in the campaign.

Johnson made just one big mistake: he gave doctors and hospitals the power to charge Medicare whatever they wished.

In Part 2 of this post I will describe how this error ultimately turned healthcare into a multi-trillion dollar industry run, not by physicians, but by corporations. I'll also explain why our for-profit healthcare industry would like to see Obama rush to roll out universal coverage at any cost--without putting the regulations in place that will be needed to constrain corporate greed and guarantee safe, affordable care. Obama cannot afford to repeat LBJ's error. If he does, corporate interests will complete their takeover of American medicine and patients' interests will be forgotten. Finally, in the second part of this post I will describe how, in contrast to the Clintons, President-elect Obama does not have to worry about the political window of opportunity closing anytime soon. This recession will not end in 2010.

This post originally appeared on HealthBeat, a project of the Century Foundation