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Two days ago, the President signed the House- and Senate- approved healthcare bill. What does this mean? On the whole, I think it’s a positive development. The perfect should not be the enemy of the good: is there anyone who seriously thought that Congress was going to do much more than this, particularly after the Massachusetts massacre (see the Feb 8th post)? And failure to pass a bill at all would have made Washington look pretty inept. Which is not a good attribute for a government, no matter which side of the political spectrum you fall on. 
My biggest concern is that passage of this bill will alleviate the pressure to do more. Everyone can now pat themselves on the back (Democrats: “We passed historic legislation”; Republicans: “We warned them not to.”) and move on to other things, like preparing for the fall elections. It may be several years before anyone is brave enough to sponsor meaningful legislation in this area again. By that time, we’ll probably be spending 25% of the GDP on healthcare and still not have the kinds of outcomes that we deserve.
The Medicare “Battle of the Bulge” (the looming demographic conflict between the bulge in the number of Medicare recipients as Baby Boomers age, and the inadequate number of wage-earners to fund the healthcare services they’ll expect) will be well underway.
I hope I’m wrong, and that someone accepts responsibility for continuing to press the issue.
WB
I had breakfast Tuesday morning with Leah Binder, the CEO of the Leapfrog Group. For those who don’t know, CPMC is one of only three hospitals in the U.S. to be a Leapfrog Top Hospital all four years the award has been given. Leah was in town for a meeting about health information systems.
As you might expect, we talked a lot about quality and patient safety. We also chatted about the status of health care reform and shared some observations. Leah mentioned some work she had done in the past indicating that many more people watched television shows about hospitals and (especially) emergency rooms than actually went to them in any year. So people’s impressions about our health care system are mostly based on what they see on TV, rather than actual experience.
On television, of course, issues like cost, access, and quality are not usually discussed. (Not to mention that almost everyone on the TV hospital’s staff is bright, energetic, and good-looking, but, hey, I’d say that’s true here at CPMC, too.) So our national dialogue about health care—such as it is—begins with a mistaken impression of reality.
I pointed out another problem: that most of us have never had health care outside the U.S. I’m reminded of the situation with American automobile manufacturers: the major impetus for producing higher quality cars was competition from Japan and Europe.
Indeed, I’m old enough to remember the days when we just assumed that the family car would spend a good chunk of its lifetime getting fixed at the local service station. It was only after some of our braver neighbors bought foreign cars that didn’t break down at all that “reliability” became an attainable and then desirable automotive attribute!
Of course, I’m not suggesting that we move to France or that we ask the French to take over our health care system (some think the French have the best health care in the world). But I am suggesting that some of our reluctance to consider other approaches may be because we don’t really know what we have (it’s not House or Grey’s Anatomy) or what we might be missing.
WB
There are many questions about health care reform but one of the biggest ones is whether we are getting our money’s worth from what we are already spending on health care.
I believe there are enormous amounts of inappropriate and wasteful care in our country—but that identifying what falls into these categories will be a gigantic challenge. For one thing, those decisions cannot be made anecdotally, as in “I knew somebody who…,” because for every anecdote that favors one decision, there’s another that supports the opposite course of action.
Decisions can’t even be made by saying, “Well, this is the way they do it in Canada (or anywhere else)”, because our system of care has been set up differently. As an example, in the entire province of Manitoba, which covers an area nearly the size of Texas and has a population of 1.2 million people, there is not a single hospital that performs cardiac surgery in children.
We face the classic problem of trying to fix an airplane while it’s flying. We are trying to keep this in mind as we plan for our future here in San Francisco. Because no matter how we decide to pay for health care in the U.S., our responsibility won’t change: we will still need to be here to provide that care efficiently and appropriately.
What does this mean for CPMC?
This responsibility explains why we are able to continue with our plans to build two new hospitals here in San Francisco during the next several years—one at our current St. Luke’s Campus, and another at Van Ness and Geary, near Cathedral Hill. Some have raised concerns about whether the expenses of these projects are going to increase the costs of health care in San Francisco. Specifically, are we going to have to borrow more than $2 billion to pay for all that new construction, and have to pay that money back, with interest, the way the City and County of San Francisco plan to pay for the new San Francisco General Hospital?
Let me reassure you that is not the case. We are going to pay for the construction with money that we have carefully been saving over the past decade (and that we will save while those new facilities are being built), along with generous donations from our friends and supporters. So that when they open in about 2015, they will be fully paid for (or close to it), which will allow us to provide health care for many decades to come without mortgaging our future.
WB
It’s not hopeless to imagine that we could redesign our health care delivery system in this country so that we can save money without reducing access. But doing so will be an enormous challenge, comparable with solving the Mideast dilemma or ending racism.
We can begin by having an open discussion about health care: Is it a political right, like the pursuit of happiness or freedom of speech? An expectation, like being able to go to high school? An earned privilege, like getting an education at a prestigious college? An economic good, like a new car? An opportunity, like having a job? Because we rarely discuss these issues, we confuse ourselves—and make it very difficult to make the kinds of changes that are going to be necessary.
My own belief is that health care is most similar to education. As a society, we could make a commitment that every American is entitled (there, I’ve used the “e word”) to the health-care equivalent, say, of a college education within the California State University system. Like in education, this health-care entitlement would be limited: not everyone who wants to go to Berkeley or Stanford, or to graduate or professional school, gets to do so.
Some may want to treat health care differently and set up a system in which everyone is entitled to the highest level of unlimited state-of-the-art care. They need to acknowledge that doing so would cost a lot more money, and they’d need to tinker at the edges (for example, should cosmetic surgery be covered?).
Or some might say that health care should be treated more like food and shelter—things we try to provide to each member of our society, but only at a very basic level.
We’ve been reluctant to have this discussion, or even to talk about having two (or more) systems of health care: public and private, for example. Or that some people can get more or better health care than others. But I can’t think of a single other aspect of our civilization that we treat the same way. Most of us don’t believe that everyone is entitled to the same housing, transportation, vacations, or even food.
We don’t even like to talk about whether health care providers should get paid based on how many procedures they perform. Or about how much money pharmaceutical, biotechnology, and medical device companies should make on their products. Or whether the government should determine how many patients certain providers can care for at a time. Or which tests or treatments health insurance shouldn’t pay for. Or whether a non-profit medical center like CPMC should be allowed or expected to earn and put away more than $2 billion so it can rebuild its hospitals to meet new earthquake standards.
None of these questions have easy answers. But it’s only by discussing these and other issues that we have any chance of improving our current system. The alternative is to passively accept that things will always be this way—because they always have been.
No matter what we decide about our health care system, we need to understand that until we decide where we want to go, our system will always look like it’s wandering around aimlessly in the dark, with more exceptions and provisions and incomprehensible thing-a-mig-jigs than those “I accept” notices that come with software we download from the Internet.
I found the recent controversy over mammography disheartening. For those who missed the uproar, the US Preventive Services Task Force, an independent group of clinical experts, recommended that we stop doing mammograms to screen women between the ages of 40 to 49 years for breast cancer, mostly because the benefits were outweighed by the costs.
This led to a huge amount of pushback, in which women who had been diagnosed with breast cancer in their 40’s because they’d had mammograms made impassioned pleas that we needed to keep on doing these tests. And opponents of the current health care reform measures suggested that this was what would happen if the government was involved in health care decisions, namely that panels of experts (even so-called “death panels”) would decide what sorts of health care would or would not be covered.
The Obama administration rather quickly distanced itself from the recommendations, seemingly because of concerns about the political fall-out about the idea of rationing health care. Indeed, some even called “rationing” the “r word” as if it were some sort of obscenity.
But here’s what few people realized, and even fewer discussed: we already ration care, even mammograms.
We don’t do routine screening mammograms in women in their 30’s, even though some women at that age develop breast cancer. We don’t do screening mammograms in men, even though men can get breast cancer, too. Even when screening mammograms are recommended, such as for women in their 50’s and 60’s, they are only done once every year or two, even though some women develop breast cancer “in between” scheduled mammograms.
The point is not whether or not to do screening mammograms—it’s to determine how often and in whom they should be done, which is exactly what rationing means.
WB
On Tuesday, I did a radio spot with Judith Klain of Project Homeless Connect (PHC) and Liz St. John of Alice radio. (CPMC is sponsoring the next session of PHC, on February 24th at the Bill Graham Civic Auditorium. I hope you can be there to help.)
Mark Rogers Photography for PHC
Liz’s questions and Judith’s answers got me thinking more about some of the issues I’ve been blogging about. No matter how you feel about the homeless and homelessness, the stuff that PHC provides—like haircuts, eyeglasses, DMV identification cards, bags of groceries, voicemail accounts, and temporary shelter—indicates how little we as a society provide routinely.
Here’s where I’m going with this. We live in a society that’s decided “It’s OK for people who are mentally ill or abuse drugs (or both) to not have a bed to sleep in or a reliable place to eat.” Even if you don’t want to decide whether you think that this position is morally defensible, it’s reality.
So why are we surprised that providing everyone with health insurance is such a difficult decision for our legislators in Washington? I’m a strong believer in the value of health care, but IMHO, food and shelter are at least as high a priority. But it looks like I must be in the minority, at least judging from what Project Homeless Connect needs to provide on a regular basis.
As always, let me know what you think.
I’d like to begin with some thoughts about what I think is going to happen with health care reform in the U.S, and what I believe needs to be done.
The current situation—by which I mean the stall in Washington—reminds me of the apocryphal story of the butterfly flapping its wings in China and causing a tornado here. It may well turn out that the silly decision made by the losing candidate in the Massachusetts Senate race (to stop campaigning over the Holiday season) caused the demise of months of hard work by our Congressional leaders.
More to the point, I think that Americans (as reflected by the voters in Massachusetts) saw too much of the “sausage-making” that goes into legislation, and became fed up with the whole process. Too many compromises led too many people saying “Sorry, this isn’t what we had in mind.”
Here’s what I think is going to happen. Nothing. Sad but true.
If we’re lucky, a few incremental changes will be passed. First, it is going to become more difficult for insurance companies to deny coverage to patients with pre-existing health conditions.
Second, the number of Americans who are eligible for Medicaid (MediCal in our state) or subsidized private insurance will increase. Beyond that, it’s still uncertain, but I don’t think there are going to be any major changes.
It’s important for everyone to understand that any changes that involve extending health insurance coverage won’t start for a few years. That’s partly because it will take a while to set up the systems, but mostly because the Federal government does not have the money to pay for these programs, and probably won’t until the economy improves.
As to the question about what needs to be done, I think we must determine where we want to go before we can decide the best way to get there. As I see it, we have three main problems related to health care in this country:
1.) Almost 50 million Americans don’t have health insurance;
2.) The costs of health care are already high, and the aging of the U.S. population (as the 75 million of us who are Baby Boomers get older) is going to increase them further;
3.) We don’t really know what we are getting for the money we are spending.
Solving the first problem (providing coverage for uninsured Americans) will only make the second problem (spending a lot of money) worse. Providing better access to care is going to cost more, not less, money.
Most of what we do in health care costs money, even if it saves lives, or reduces disability and suffering. Requiring (as many politicians have indicated) that programs be “cost-neutral” is simply wishful thinking right now. If we want to provide better and more access to care, we need to be prepared to spend more money.
That isn’t to say that we can’t identify ways to reduce the costs of health care in this country, just that doing so will be difficult. Why? Because we don’t appear to be willing to make the hard choices about what to stop spending money on. Especially when it’s not clear to us whose money we are spending. We like to make believe that it’s not our own money: someone else pays for our health care. But, of course, we are spending our own money; we just don’t realize it, at least not yet. And when it comes to spending less on health care, no one wants to go first. We all just keep waiting for someone else to volunteer.
If you think I’m kidding about this, drop me a note saying what you’re personally willing to give up, either in terms of health care as a patient, or in terms of salary or benefits as a health care employee!
WB
