April 18, 2004
Now Can We Talk About Health Care?
I know what you're thinking. Hillary Clinton and health care? Been there. Didn't do that!
No, it's not 1994; it's 2004. And believe it or not, we have more problems today than we had back then. Issues like soaring health costs and millions of uninsured have yet to fix themselves. And now we are confronting a new set of challenges associated with the arrival of the information age, the technological revolution and modern life.
Think for a moment about recent advances in genetic testing. Knowing you are prone to cancer or heart disease or Lou Gehrig's disease may give you a fighting chance. But just try, with that information in hand, to get health insurance in a system without strong protections against discrimination for pre-existing or genetic conditions. Each vaunted scientific breakthrough brings with it new challenges to our health system. But it's not only medicine that is changing. So, too, are the economy, our personal behaviors and our environment. Unless Americans across the political spectrum come together to change our health care system, that system, already buckling under the pressures of today, will collapse with the problems of tomorrow.
Twenty-first-century problems, like genetic mapping, an aging population and globalization, are combining with old problems like skyrocketing costs and skyrocketing numbers of uninsured, to overwhelm the 20th-century system we have inherited.
The way we finance care is so seriously flawed that if we fail to fix it, we face a fiscal disaster that will not only deny quality health care to the uninsured and underinsured but also undermine the capacity of the system to care for even the well insured. For example, if a hospital's trauma center is closed or so crowded that it cannot take any more patients, your insurance card won't help much if you're the one in the freeway accident.
Let's face it -- if we were to start from scratch, none of us, from dyed-in-the-wool
liberals to rock-solid conservatives, would fashion the kind of health care system America
has inherited. So why should we carry the problems of this system into the future?
Since then, a century's worth of advances yielded remarkable results. Antibiotics were developed. Anesthesia was improved. Public health programs like mosquito control and childhood immunizations succeeded in reducing or even eradicating diseases like malaria and polio in this country. Congress passed legislation regulating the quality of food and drugs and assuring that safety and science guided medical developments. Workplace and product-safety standards resulted in fewer deaths and injuries from accidents. Effective campaigns cut tobacco use and alcohol abuse. Employers began providing some workers with health care coverage, primarily for hospitalization costs. And to aid some of those left out, President Lyndon B. Johnson persuaded Congress to establish Medicare and Medicaid to address the poorest, sickest, oldest and highest-risk patients in our society. As a result of these accumulated gains, life expectancy grew from 47 years in 1900 to 77 years for those born in 2000.
As astounding as those changes were, we are likely to see even more revolutionary changes in the next 100 years. Advances in medicine coincide with advances in computers and communications. The American workplace is changing in response to global pressures. But even positive advances may come with a negative underside. Our affluence contributes to an increasingly sedentary lifestyle that, combined with a diet filled with sugar and fat-rich foods, undermines our ability to fend off chronic diseases like diabetes. And research is proving that the pollutants and contaminants in our environment cause disease and mortality.
It is overwhelming just thinking about the problems, never mind dealing with them. But
we have to begin applying American ingenuity and resolve or watch the best health care
system in the world deteriorate.
Think about the potential for inequities in drug research. Today, pharmaceutical and biotech companies have little incentive to research and develop treatments for individuals with rare diseases. Never heard of progeria? That's the point. This fatal syndrome, also called premature-aging disease, affects one in four million newborns a year. It's rare enough that there is no profit in developing a cure. This is known as the ''orphan drug'' problem. Genetic profiles and individualized therapies have the potential to increase the problem of orphaned drugs by further fragmenting the market. Even manufacturers of drugs for conditions like high blood pressure might focus their efforts on people with common genetic profiles. Depending on your genes, you could be out of luck.
The increasing understanding and use of genomics may also undermine the insurance system. Health insurance, like other insurance, exists to protect against unpredictable, costly events. It is based on risk. As genetic information allows us to predict illness with greater certainty, it threatens to turn the most susceptible patients into the most vulnerable. Many of us will become uninsurable, like the two young sisters with a congenital disease I met in Cleveland. Their father went from insurance company to insurance company trying to get coverage, until one insurance agent looked at him and said, ''We don't insure burning houses.''
Many have worked to get laws on the books to protect people from genetic discrimination, but we have yet to pass legislation that addresses job security and health coverage. The challenges do not stop there. Health insurance will have to change fundamentally to cope with predictable, knowable risks. Will health insurance companies offer coverage tailored to a person's future health prospects? Right now, if you have asthma, or even just allergies, insurers in the individual market can exclude your respiratory system from your health insurance policy. Will all health plans stop offering benefits that relate to genetic diseases?
The ability to predict illness may overwhelm more than just the insurance system; it may overwhelm the patient and the provider. Studies in The Journal of the American Medical Association found that nearly 6 out of 10 patients at risk for breast and ovarian cancer declined a genetic test, and a similar fraction of those at risk for colon cancer also declined testing. Why? One reason is probably to avoid higher insurance premiums. But the decision to undergo genetic testing is a complex one that involves many issues. Positive test results often indicate increased risk but no certainty that a disease will occur. Negative results also come without guarantees. The development of genetic profiles and individual therapies will exponentially increase the amount of information a physician is expected to manage. Instead of remembering one or two drugs for any condition, a physician will have to analyze all the different genetic, demographic and behavioral variables to generate optimal treatment for a patient.
Medical advances have the potential to overwhelm the health care system top to bottom.
At the very least, the pace of technological progress is so rapid that our antiquated
health care system is ill equipped to deliver the fruits of that progress. But these
advances are not occurring in isolation from other factors affecting both how we finance
health care and how much care we need and expect.
The United States' closest economic rivals have mandatory national health care systems rather than the voluntary employer-based model we have. Automakers in the United States and Canada pay taxes to help finance public health care. But in the United States, automakers also pay about $1,300 per midsize car produced for private employee health insurance. Automakers in Canada come out ahead, according to recent news reports, even after paying higher taxes.
At the same time, American companies are outsourcing jobs to countries where the price of labor does not include health coverage, which costs Americans jobs and puts pressure on employers who continue to cover their employees at home.
And many new jobs, especially those in the service sector and part-time jobs, don't include comprehensive health benefits. More uninsured and underinsured workers impose major strains on a health system that relies on employer-based insurance. In addition, the failure of government to help contain health costs for employers has led to a fraying of the implicit social contract in which a good job came with affordable coverage.
Gone are the days when a young person would start in the mail room and stay with the company until retirement. Employee mobility is now the rule rather than the exception. Those who pay for health care -- insurance companies and employers -- increasingly deal with employees who change jobs every few years. This has the effect of not only increasing the numbers of uninsured but also of decreasing the incentive for employers to underwrite access to preventive care.
At the same time, war, poverty, environmental degradation and increased world travel for business and pleasure mean greater migration of people across borders. And with people go diseases. The likes of SARS can travel quickly from Hong Kong to Toronto, and news of a strange flu in Asia worries us in New York. Welcome to the world without borders.
The Pulitzer Prize-winning science writer Laurie Garrett has described it as ''payback
for decades of shunning the desperate health needs of the poor world.'' No matter the
blame, the need to act now to address issues of global health is no longer just a moral
imperative; it is self-interest.
In three decades, the number of Medicare beneficiaries will double. By the year 2050, one in five Americans will be 65 or older. We will have to find a way to finance the growing demand not only for health care but also for long-term care, which is now largely left out of Medicare.
Our society's affluence is only half of the story. Widening disparities in wealth and in health care too often cleave along ethnic lines. Today, a Hispanic child with asthma is far less likely than a non-Hispanic white child to get needed medication. African-Americans are systematically less likely to get state-of-the-art cardiac care. As our country becomes more and more diverse, these disparities become more obvious and more intolerable.
Our changing lifestyles also contribute to behavior-induced health problems. We can
shop online, order in fast food, drive to our errands. Entertainment -- movies, TV, video
games and music -- is one click away. The physical activity required to get through the
day has decreased, while the pace and stress of daily life has quickened, affecting mental
health. Persistent poverty, risky behaviors like substance abuse and unprotected sex and
pollution from cars and power plants all add to the country's health problems. As Judith
Stern of the University of California at Davis so aptly put it, genetics may load the gun,
but environment pulls the trigger.
In 1993, the critics predicted that if the Clinton administration's universal health care coverage plan became law, costs would go through the roof. ''Hospitals will have to close,'' they said, ''Families will lose their choice of doctors. Bureaucrats will deny medically necessary care.''
They were half-right. All that has happened. They were just wrong about the reason.
In 1993, there were 37 million uninsured Americans. In the late 90's, the situation improved slightly, largely because of the improved economy and the passage of the Children's Health Insurance Program. But now some 43.6 million Americans are uninsured, and the vast majority of them are in working families.
While employer-sponsored insurance remains a major source of coverage for workers, it is becoming less accessible and affordable for spouses, dependents and retirees. In 1993, 46 percent of companies with 500 or more employees offered some type of retiree health benefit. That declined to 29 percent in 2001. When you think about the new economy and worker mobility, it's no wonder employers are dropping retiree health benefits. You can only wonder how many yet-to-retire workers are next.
Even those Americans not among the ranks of the uninsured increasingly find themselves underinsured. In 2003, two-thirds of companies with 200 or more employees dealt with increasing costs by increasing the share that their employees had to pay and dropping coverage for particular services. With rising deductibles and co-pays, even if you have insurance, you may not be able to afford the care you need, and some benefits, like mental health services, may not be covered at all.
The problem of the uninsured and underinsured affects everyone. A recent Institute of Medicine study estimates that 18,000 25- to 64-year-old adults die every year as a result of lack of coverage. But even if you are insured, if you have a heart attack, and the ambulance that picks you up has to go three hospitals away because the nearby emergency rooms are full, you will have suffered from our inadequate system of coverage.
If, as a nation, we were saving money by denying insurance to some people, you could at least say there's some logic to it -- no matter how cruel. But that's not the case. Despite the lack of universal coverage in our country, we still spend much more than countries that provide health care to all their citizens. We are No. 1 in the world in health care spending. On a per capita basis, health spending in the United States is 50 percent higher than the second-highest-spending country: Switzerland. Our health costs now constitute 14.9 percent of our gross domestic product and are growing at an alarming rate: by 2013, per capita health care spending is projected to increase to 18.4 percent of G.D.P.
What drives skyrocketing spending? The cost of prescription drugs rose almost twice as fast as spending on all health services, 40 percent in just the last few years.
Hospital costs have been rising as well, in large measure because more than one in four health care dollars go to administration. In 1999, that meant $300 billion per year went to pay for administrative bureaucracy: accountants and bookkeepers, who collect bills, negotiate with insurance companies and squeeze every possible reimbursement out of public programs like Medicare and Medicaid. Asthma and other pulmonary disorders linked to pollution contribute significantly to these costs, according to the health economist Ken Thorpe. Diabetes, high blood pressure and mental illness are also among the conditions that keep these costs rising.
If we spend so much, even after administrative costs, why does the United States rank behind 47 other countries in life expectancy and 42nd in infant mortality?
A lot of the money Americans spend is wasted on care that doesn't improve health. A recent study by Dartmouth researchers argues that close to a third of the $1.6 trillion we now spend on health care goes to care that is duplicative, fails to improve patient health or may even make it worse. A study in Santa Barbara, Calif., found that one out of every five lab tests and X-rays were conducted solely because previous test results were unavailable. A recent study found that for two-thirds of the patients who received a $15,000 surgery to prevent stroke, there was no compelling evidence that the surgery worked.
In situations in which the benefits of intervention are clear, many patients are not receiving that care. For example, few hospitalized patients at risk for bacterial pneumonia get the vaccine against it during their hospital stays. A recent study in The New England Journal of Medicine by Elizabeth McGlynn found that, overall, Americans are getting the care they should only 55 percent of the time.
As a whole, our ailing health care system is plagued with underuse, overuse and misuse.
In a fundamental way, we pay far more for less than citizens in other advanced economies
First, the way we deliver health care must change. For too long our model of health care delivery has been based on the provider, the payer, anyone but the patient. Think about the fact that our medical records are still owned by a physician or a hospital, in bits and pieces, with no reasonable way to connect the dots of our conditions and our care over the years.
If we as individuals are responsible for keeping our own passports, 401(k) and tax files, educational histories and virtually every other document of our lives, then surely we can be responsible for keeping, or at least sharing custody of, our medical records. Studies have shown that when patients have a greater stake in their own care, they make better choices.
We should adopt the model of a ''personal health record'' controlled by the patient, who could use it not only to access the latest reliable health information on the Internet but also to record weight and blood sugar and to receive daily reminders to take asthma or cholesterol medication. Moreover, our current system revolves around ''cases'' rather than patients. Reimbursements are based on ''episodes of treatment'' rather than on a broader consideration of a patient's well-being. Thus it rewards the treatment of discrete diseases and injuries rather than keeping the patient alive and healthy. While we assure adequate privacy protections, we need care to focus on the patient.
Our system rewards clinicians for providing more services but not for keeping patients
healthier. The structure of the health care system should shift toward rewarding doctors
and health plans that treat patients with their long-term health needs in mind and
rewarding patients who make sensible decisions about maintaining their own health.
Ten years ago, the Internet was used primarily by academics and the military. Now it is possible to imagine all of a person's health files stored securely on a computer file -- test results, lab records, X-rays -- accessible from any doctor's office. It is easy to imagine, yet our medical system is not there.
The average emergency-room doctor or nurse has minutes to gather information on a patient, from past records and from interviewing the patient or relatives. In the age of P.D.A.'s, why are these professionals forced to rely on a patient's memory?
Information technology can also be used to disseminate research. A government study recently documented that it takes 17 years from the time of a new medical discovery to the time clinicians actually incorporate that discovery into their practice at the bedside. Why not 17 seconds?
Why rely solely on the doctor's brain to store that information? Computers could crunch the variables on a particular patient's medical history, constantly update the algorithms with the latest scientific evidence and put that information at the clinician's fingertips at the point of care.
Americans may not be getting the care they should 45 percent of the time, but the tools exist to narrow that gap. Research shows that when physicians receive computerized reminders, statistics improve exponentially. Reminders can take the form of an alert in the electronic health record that the hospitalized patient has not had a pneumonia vaccine or as computerized questions to remind a doctor of the conditions that must be fulfilled before surgery is considered appropriate.
Newt Gingrich and I have disagreed on many issues, including health care, but I agree with some of the proposals he outlines in his book ''Saving Lives and Saving Money,'' which support taking advantage of technological changes to create a more modern and efficient health care system. I have introduced legislation that promotes the use of information technology to update our health care system and organize it around the best interests of patients. Improvements in technology will end the paper chase, limit errors and reduce the number of malpractice suits.
I strongly believe that savings from information technology should not just be diffused
throughout the system, never to be recaptured, but should be used to make substantial
progress toward real universal coverage. By better using technology, we can lower health
care costs throughout the system and thereby lower the exorbitant premiums that are
placing a financial squeeze on businesses, individuals and the government. At the same
time, some of those savings should be used to make substantial progress toward real
universal coverage. (I may have just lost Newt Gingrich.)
If asthma and other pulmonary disorders are the main drivers of increased health spending, that argues strongly that we should rethink how social and environmental factors impact our collective health. Consider that over the last century we have extended life expectancy by 30 years but that only 8 of those years can be credited to medical intervention. The rest of our gains stem from the construction of water and sewer systems, draining mosquito-infested swamps and addressing spoilage, quality and nutrition in our food supply. Yet we continue to underinvest in these important systematic measures -- resulting in expensive health consequences like the explosion of asthma among children living in New York City or the harmful levels of lead found among children drinking water from the District of Columbia water system.
Our neglect of public health also contributes to spiraling health costs. We tend to address health care -- as a nation and as individuals -- after the sickness has taken hold, rather than addressing the cause through public health. Public health programs can help stop preventable disease and control dangerous behaviors. Take obesity, for example. Individuals should understand that they put their lives at risk with unhealthy behavior. But let's face it -- we live in a fast-food nation, and we need to take steps, like restoring physical-education programs in schools, that support the individual's ability to master his or her own health. Studies conducted by the Centers for Disease Control and Prevention have identified ''Programs That Work,'' which should be financed. It comes down to individual responsibility reinforced by national policy.
The public health system also needs to be brought up to date. The current public health tools were developed when the major threats to health were infectious diseases like malaria and tuberculosis. But now chronic diseases are the No. 1 killer in our country. We need to be concerned not just about pathogens but also about carcinogens.
Over the last three years, I have introduced legislation to increase investment in tracking and correlating environmental and health conditions. I have met with people from Long Island to Fallon, Nev., who want answers about cancer clusters in their communities. The data we have seen about lead and mercury contamination in our food and water suggest that the effects they have on the fetus and children may have contributed to the increasing number of children in special education with attention and learning disorders. We need more research to determine once and for all if increasing pollution in our communities and increasing rates of learning-related disabilities are cause and effect.
We should also be looking at sprawl -- talking about the way we design our neighborhoods and schools and about our shrinking supply of safe, usable outdoor space -- and how that contributes to asthma, stress and obesity. We should follow the example of the European Union and start testing the chemicals we use every day and not wait until we have a rash of birth defects or cancers on our hands before taking action. And we should look at factors in our society that lead to youth violence, substance abuse, depression and suicide and ultimately require insurance and treatment for mental health.
After Sept. 11, mental health was a significant factor in the health toll on our nation's first responders. And yet our mental health delivery system is underfinanced and unprepared.
Finally, as a society, we need greater emphasis on preventive care, an investment in
people and their health that saves us money, because when families can't get preventive
care, they often end up in the emergency room -- getting the most expensive care possible.
For the first time, this year a nonpartisan group dedicated to improving the nation's health, the Institute of Medicine, recommended that by 2010 everyone in the United States should have health insurance. Such a system would promote better overall health for individuals, families, communities and our nation by providing financial access for everyone to necessary, appropriate and effective health services.
It will, as I have been known to say, take the whole village to finance an affordable and accountable health system. Employers and individuals would share in its financing, and individuals would have to assume more responsibility for improving their own health and lifestyles. Private insurers and public programs would work together, playing complementary roles in ensuring that all Americans have the health care they need. Our society is already spending $35 billion a year to treat people who have no health insurance, and our economy loses $65 billion to $130 billion in productivity and other costs. We are already spending what it would cost if we reallocated those resources and required responsibility.
In the post 9/11 world, there is one more reason for universal coverage. The anthrax and ricin episodes, and the continuing threat posed by biological, chemical and radiological weapons, should make us painfully aware of the shortcomings of our fragmented system of health care. Can you imagine the aftermath of a bioterrorism attack, with thousands of people flooding emergency rooms and bureaucrats demanding proof of insurance coverage from each and every one? Those without coverage might not see a doctor until after they had infected others.
Insurance should be about sharing risk and responsibility -- pooling resources and risk to protect ourselves from the devastating cost of illness or injury. It should not be about further dividing us. Competition should reward health plans for quality and cost savings, not for how many bad risks they can exclude -- especially as we enter the genomic age, when all of us could have uninsurable risks written into our genes.
So achieving comprehensive health care reform is no simple feat, as I learned a decade ago. None of these ideas mean anything if the political will to ensure that they happen doesn't exist.
Some people believe that the only solution to our present cost explosion is to shift the cost and risk onto individuals in what is called ''consumer driven'' health care. Each consumer would have an individual health care account and would monitor his or her own spending. But instead of putting consumers in the driver's seat, it actually leaves consumers at the mercy of a broken market. This system shifts the costs, the risks and the burdens of disease onto the individuals who have the misfortune of being sick. Think about the times you have been sick or injured -- were you able under those circumstances to negotiate for the best price or shop for the best care? And instead of giving individuals, providers and payers incentives for better care, this cost-shifting approach actually causes individuals to delay or skip needed services, resulting in worse health and more expensive health needs later on.
Meanwhile, proposals like those for individual health insurance tax credits, without reforms for the individual insurance market, leave individuals in the lurch as well. We know that asthmatics can have their entire respiratory systems excluded from coverage. Individual insurance companies can increase your premium or limit coverage for factors like age, previous medical history or even flat feet. Those in the individual market cannot pool their risk with colleagues or other members of the group. The coverage you can get and the price you pay for it will reflect individual risk, and you simply don't receive many of the benefits of what we consider traditional insurance when people pool risks. So the proposal to give individuals tax credits to buy coverage in the individual market, without any rules of fair play, won't provide much help for Americans who need health care. In the same way, the recent Medicare bill, which seeks to privatize Medicare benefits, long a government guarantee, threatens to leave the ''bad risks'' without any affordable coverage. With the new genetic information at our disposal, that could mean any one of us could one day be denied health insurance.
When many of those who opposed the Health Security Act look back, they are still proud of their achievement in blocking our reform plan. The focus of that proposal was to cover everybody by enabling the healthier to pool the ''risk'' with others. The plan was to redirect what we currently pay for uninsured care into expanding health coverage.
We could make cosmetic changes to the system we currently have, but that would simply take what is already a Rube Goldberg contraption and make it larger and even more unwieldy. We could go the route many have advocated, putting the burden almost entirely on individuals, thereby creating a veritable nationwide health care casino in which you win or lose should illness strike you or someone in your family. Or we could decide to develop a new social contract for a new century premised on joint responsibility to prevent disease and provide those who need care access to it. This would not let us as individuals off the hook. In fact, joint responsibility demands accountability from patients, employers, payers and society as a whole.
What will we say about ourselves 10 years from today? If we finally act to reform what we know needs to change, we may take credit in building a health care system that covers everyone and improves the quality of all our lives. But if we continue to dither and disagree, divided by ideology and frozen into inaction by competing special interests, then we will share in the blame for the collapse of health care in America, where rising costs break the back of our economy and leave too many people without the medical attention they need.
The nexus of globalization, the revolution in medical technology and the seismic pressures imposed by the contradictions in our current health care system will force radical changes whether we choose them or not. We can do nothing, we can take incremental steps -- or we can implement wide-ranging reform.
To me, the case for action is clear. And as we work to develop long-term solutions, we
can take steps now to help address the immediate problems we face. As
We can pass real privacy legislation that will ensure that Americans continue to feel secure in the trust they place in others for their most intimate medical information. And we can realize the promise of savings through information technology and disease management by passing quality health legislation now.
If we do not fix the problems of the present, we are doomed to live with the consequences in the future. As someone who tried to promote comprehensive health care reform a decade ago and decided to push for incremental changes in the years since, I still believe America needs sensible, wide-ranging reform that leads to quality health care coverage available to all Americans at an affordable cost.
The present system is unsustainable. The only question is whether we will master the
change or it will master us.
Hillary Rodham Clinton is a Democratic senator from New York.