Health Care Reform: Whats Public Health Got to Do With It

1
Health Care ReformWhats Public Health Got to
Do With It?

• Jack Thompson
• University of Washington School of Public Health
  and Community Medicine
• Arizona Public Health Association Spring
  Conference
• April 10, 2008

2
Points to Cover in the Next Hour

• Discuss the connection between public health and
  health care reform
• Present model criteria for analysis
• Review the health care reform platforms of the
  presidential candidates
• Summarize approaches and discuss options for
  future work

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Socialized Medicine

• A system of health care in which all health
  facilities are owned by the government. Doctors
  and other health care personnel work for the
  government and draw their salaries from the
  government.
• We arent talking about that today
• But there are examples of this in the American
  Health Care System.
• The US Veterans Administration
• The Armed Services

4
Single Payer

• A system of health care that provides universal
  and comprehensive coverage, with the government
  as the insurer issuing the payments.
• In single payer, the government would NOT be the
  primary provider of health care. It would just
  be the primary payer. There would still be
  freedom to choose doctors and other health care
  professionals, facilities, and services.
• But more about that from Dr. Jarvis we wont be
  talking about that here, either.
• It is not a characteristic of any active
  candidates approach to health care reform
  (depending on how you view the Nader candidacy)

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Definitions I Will Use

• Personal Health Services/Medical Care
• Diagnosis and treatment of disease or provision
  of clinical preventive services to individuals or
  families in order to improve individual health
  status
• Population-based Public Health Services
• Interventions aimed at disease prevention and
  health promotion that affect an entire population
  and extend beyond medical treatment by targeting
  underlying risks

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• There is no better illustration of the dilemmas
  of rational policy making in America than in the
  field of healththe first obstacle to rationalism
  is defining the problem. Is our goal to have
  good health - that is, whether we live at all
  (infant mortality), how well we live (days lost
  to sickness), and how long we live (life spans
  and adult mortality)? Or is our goal to have
  good medical care - frequent visits to the
  doctor, well-equipped and accessible hospitals,
  and equal access to medical care by rich and poor
  alike?
• Thomas Dye Understanding Public Policy

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From The Future of the Publics Health in the
21st Century

• Recommendation 18
• Adequate population health cannot be achieved
  without making comprehensive and affordable
  health care available to every person residing in
  the United States. It is the responsibility of
  the federal government to lead a national effort
  to examine the options available to achieve
  stable health care coverage of individuals and
  families and to assure the implementation of
  plans to achieve that result.

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The American Health Care System Is a MESS

• Cost
• U.S. health care costs per person are 75-250
  higher than any other developed nation
• Access
• 47 million Americans (16) are uninsured
• The uninsured are less likely to get the care
  they need
• Quality
• Despite technology knowledge advantages, the
  quality of U.S. health care is mediocre at
  best

New England Journal of Medicine, 354(11), March
2006 (report on RAND Corp study, funded by Robert
Wood Johnson Foundation)
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Non-Financial Access Barriers System Factors

• system capacity/provider supply
• poor coordination of services
• lack of usual source/lack of continuity of care
• inadequate tracking and outreach
• provider communication/attitude
• lack of childcare
• lack of transportation

• discrimination
• cultural competency
• convenience hours, sites, waiting times
• bureaucratic complexity and unfriendliness
• managed care/provider reimbursement incentives
• Medicaid not accepted

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Challenges in Assuring Access

• Continued increases in medical costs
• Insurers dropping higher-cost people
• Continued erosion of private insurance coverage
• Employment-based insurance excludes many
• Retirees lose health benefits

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Challenges in Assuring Access

• Elimination of provider cost-shifting in
  competitive environment
• Erosion of continuity of care in competitive
  managed care market
• Threats to public hospitals
• Disruption of safety net by market forces and
  decreasing public funds for health services
• Increasing cost-shifting to consumers and
  employees
• Growth of managed care may add additional access
  barriers for low-income populations

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A Broader Context

• From
• Evans, RG and GL Stoddart. Producing Health,
  Consuming Health Care. Soc. Sci.Med. 1990. Vol.
  31(12) 1347 1363.

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Need, Access
Other
Health Care
Disease
Factors
Cure, Care
14
Growing Health Care Costs
Other
Health Care
Disease
Factors
Cure, Care
Clinical Epidemiology, Health Care Evaluation,
Health Services Research, etc.
15
Social Environment
Genetic Endowment
Physical Environment
Individual Response -Behavior -Biology
Health Function
Health Care
Disease
Well-Being
Prosperity
16
Factors that Influence Health Status
Influence
National Health
Expenditures

1.2 Trillion
10 20 20 50
Sources Centers for Disease Control and
Prevention, University of California at San
Francisco, Institute for the Future. Reprinted
from Advances The Robert Wood Johnson Foundation
Quarterly Newsletter, 2000, Issue 1, supplement,
page 1
17

• Committee on Assuring the Health of the Public in
  the 21st Century

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Approach and rationale
A guide to thinking about the determinants of
population health
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From The Future of the Publics Health in the
21st Century

• Recommendation 18
• Adequate population health cannot be achieved
  without making comprehensive and affordable
  health care available to every person residing in
  the United States. It is the responsibility of
  the federal government to lead a national effort
  to examine the options available to achieve
  stable health care coverage of individuals and
  families and to assure the implementation of
  plans to achieve that result.

20
From The Future of the Publics Health in the
21st Century

• Recommendation 19
• All public and privately funded insurance plans
  should include age-appropriate preventive
  services as recommended by the U.S. Preventive
  Services Task Force and provide evidence-based
  coverage of oral health, mental health, and
  substance abuse treatment services.

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From The Future of the Publics Health in the
21st Century

• Specific types of care that are important for
  population health
• Clinical preventive services
• Mental health care
• Treatment for substance abuse
• Oral health care

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From The Future of the Publics Health in the
21st Century

• Problems in Quality of Care
• Two particular quality problems have special
  significance in terms of assuring the health of
  the population
• Disparities in the quality of care provided to
  racial and ethnic minorities
• Inadequate management of chronic diseases

23
APHA 14 Points on Universal Health Care Toward
a National Health Program for the United States

• 1. Universal coverage for everyone in the
  United States.
• 2. Comprehensive benefits including health
  maintenance, preventive, diagnostic,
  therapeutic, and rehabilitative services for all
  types of illnesses and health conditions.
• 3. Elimination of financial barriers to care.
• 4. Financing based on ability to pay.
• 5. Organization and administration of health
  care through publicly-accountable mechanisms to
  assure maximum responsiveness to public needs,
  with a major role for federal, state, and local
  government health agencies.

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APHA 14 Points on Universal Health Care Toward
a National Health Program for the United States

• 6. Incentives and safeguards to assure effective
  and efficient organization of services and
  high-quality care.
• 7. Fair payment to providers using mechanisms
  which encourage appropriate treatment by
  providers and appropriate utilization by
  consumers.
• 8. Ongoing evaluation and planning to improve
  the delivery of health services with consumer
  and provider participation.
• 9. Inclusion of disease prevention and health
  promotion programs.

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APHA 14 Points on Universal Health Care Toward
a National Health Program for the United States

• 10. Support of education and training programs
  for all health workers.
• 11. Affirmative action programs in the training,
  employment, and promotion of health workers.
• 12. Non-discrimination in the delivery of health
  services.
• 13. Education of consumers about their health
  rights and responsibilities.
• 14. Attention in the organization, staffing,
  delivery, and payment of care to the needs of
  all populations including those confronting
  geographic, physical, cultural, language, and
  other non-financial barriers to service.

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From the Commonwealth Fund Commission on a High
Performance Health SystemPrinciples for Health
Insurance Reform

• Access to Care
• Provides equitable and comprehensive insurance
  for all
• Insures the population in a way that leads to
  full and equitable participation
• Provides a minimum, standard benefit floor for
  essential coverage with financial protection
• Premiums, deductibles, and out-of-pocket costs
  are affordable relative to family income
• Coverage is automatic and stable with seamless
  transitions to maintain enrollment
• Provides a choice of health plans or care systems

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From the Commonwealth Fund Commission on a High
Performance Health SystemPrinciples for Health
Insurance Reform

• Quality, Efficiency, and Cost Control
• Fosters efficiency by reducing complexity for
  patients and providers, and reducing transaction
  and administrative costs as a share of premiums
• Works to improve health care quality and
  efficiency through administrative reforms,
  provider profiling and network design,
  utilization management, pay-for-performance
  payment models, and structures that encourage
  adherence to clinical guidelines
• Minimizes dislocation people can maintain
  current coverage if desired
• Is simple to administer
• Health risks are pooled across broad groups and
  lifespans insurance practices designed to avoid
  individuals with poor health risks are eliminated
• Has the potential to lower overall health care
  cost growth

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From the Commonwealth Fund Commission on a High
Performance Health SystemPrinciples for Health
Insurance Reform

• Financing
• Financial commitment is necessary to achieve
  these principles
• Financing should be adequate and fair, based on
  ability to pay, and should be the shared
  responsibility of federal and state governments,
  employers, individual households, and other
  stakeholders

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Factors to Consider in Reviewing Candidate Health
Platforms or in Advocacy Work

• IOM Recommendations
• Population-related care coverage (preventive
  services, mental health, substance abuse, oral
  health)
• Quality of care related to disparities and
  chronic disease
• APHA 14 Points
• Commonwealth Fund Principles
• Linkages with income maintenance and education
• Cost containment through system reform

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2008 Presidential Candidates Approaches to Health
Care Reform

• Tax Incentives for Individual Market Insurance
  (McCain)
• Mixed Private-Public Group Insurance with Shared
  Responsibility for Financing (Clinton and Obama)
• Public Insurance (Nader and Kucinich approach
  not a factor in current debates)

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Clinton Health Plan

• Require everyone to get health insurance,
  subsidized by employers and the government
• Three components lowering costs, improving
  quality, insuring everyone
• Pay for it by rolling back tax cuts for
  households earning over 250,000 and savings in
  the existing system
• Addresses prevention and chronic disease
  management
• Addresses disparities

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Obama Health Plan

• Require that all children have health insurance
  aims for universal coverage
• Require employers to provide insurance or
  contribute to the cost (exempt smallest
  businesses and reimburse employers for
  catastrophic health costs).
• Create purchasing pool with choice of competing
  private plans and one public plan like Medicare.
  
• Expand Medicaid, State Childrens Health
  Insurance Program
• Addresses prevention and chronic disease
  management and disparities

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McCain Health Plan

• For free-market, consumer-based system opposes
  mandate requiring everyone to obtain health
  insurance
• Provide tax credits for insurance purchase
• Has pledged affordable health care for every
  American without a tax increase
• Addresses prevention and chronic disease
  management
• Does not specifically address disparities

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Features of Candidates Approaches to Health Care
Reform(from The Commonwealth Fund Commission on
a High Performance Health System)
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Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
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WASHINGTON HEALTH CARE COMMISSION FINAL REPORT
(11/30/92)

• The health systemmust go beyond ensuring access
  to and controlling costs of medical care.
  Services we traditionally think of as medical
  care - those provided by physicians, hospitals,
  nursing homes, and dentists - are critical, but
  they are only part of the health system.
• The Commission envisions a health system which
  integrates policies designed to improve both the
  health status of the entire population (public
  health) and that of individuals (personal
  health). This can be accomplished by combining a
  strengthened public health system with changes in
  the personal health services delivery system.
  This integration would result in an overall
  health system that protects and improves the
  health status of allresidents.

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WASHINGTON HEALTH CARE COMMISSION FINAL REPORT
(11/30/92)

• The Commission recommends ensuring universal
  access to a uniform set of health services.
  This includes a uniform benefits package of
  personal health services to be provided by
  certified health plans, and population-based,
  non-insured health services to be provided
  primarily through the public health system.
• The uniform set of health services consists of
  all services to whichresidents are ensured
  access. The uniform set includes (1) an insured
  uniform benefits package comprised of personal
  health services provided by certified health
  plans, and (2) a variety of non-insured services
  provided primarily by the public health systems.
  The uniform set consists of three major
  components personal health services, core public
  health functions, and health system support.

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