|
| |
The Future of US Health Care
From: Columbia University
| By:
Steven A. Schroeder |
EDITOR'S INTRODUCTION |
A complex interaction of scientific and social factors creates what we know as health. Health is as much a personal responsibility as a societal one, with improvements in American health dependent on individual action and governmental action.  Though the science of health care is constantly advancing, harmful behavioral habits, ignorance of health information and options, and limited access to health care are preventing technological treatments from reaching many who could benefit from them. Rising health care expectations and spending conflicts are likely to continue, as individuals become more educated about health and treatment options and as social stratification remains a barrier to health care access. Steven A. Schroeder, M.D. (above), president of the Robert Wood Johnson Foundation, advocates improving health in the coming century by improving health habits and instigating governmental changes in health policy. |
 hough health care may be less crucial in improving the population's health, we all want it when we need it, and it is the stuff of the polls, elections and politicians. Every nation, whether rich or poor, struggles with managing rising expenditures for medical care. Since in most countries the bulk of medical payments come from governmental sources, the issue is by definition a political one--even in the United States, which is the only established market economy that does not provide health insurance to all citizens. About half of all medical care is paid by government sources, either Medicare, Medicaid, the state, or the VA campus. Though the US trails other nations in the percentage of people covered by health insurance, it leads the world in medical care expenditures. There is great concern about whether Americans are getting proper value for their medical care dollars. While the US outspends the world in health expenditures, it ranks anywhere from 19th to 22nd in traditional health status measurements such as infant mortality rates and life expectancy from birth. |
 | |
| Schroeder discusses how public health is addressed by the mass media. | |
We have a very different country. Politicians will be under enormous pressure to provide more health care, even though the real benefits may be modest or possibly injurious, as in the case of bone marrow transplants for breast cancer patients. The pressures from the health care industry and from patients desperate for a cure forced approval of procedures that were not scientifically proven. |
It is no accident that our country spends so much on medical care, for we are abundantly endowed with expensive medical technology. We have the highest number of technologies per person, the greatest concentration of health workers who apply those technologies, the highest technology cost and the highest volume of use. Forty-four million people are not covered by health insurance in the United States, and that figure has been steadily rising. While insurance coverage is not the only determinant of health care access, it is unquestionably the major one. The US ranks first or second in the world in life expectancy after age 65. This population is fully insured, with access to our nation's sophisticated medical technology. Those who argue that the poor get enough health care despite lacking health insurance are wrong. |
The statistics about cost and technology in the US mask some fundamental regional differences in patterns of care. For example, there are twofold fewer hospital beds per capita in Seattle than Chicago. Similarly, end-of-life health care is far better on average in Minneapolis than in Miami, where there is a twofold higher hospital cost, twofold higher admission rate to the Intensive Care Unit (ICU), and a threefold longer stay in the ICU. The tension between cost and coverage has reached a new level in the United States. What had previously seemed to be an inexorable spiral of uncontrollable medical costs came to a screeching halt in 1992. To the astonishment of analysts, medical care expenditures have remained at 13.6 percent of gross domestic product since then. The congressional budget office in 1992 projected that by the year 2000 that number would reach 20 percent. |
This period of cost containment has increased the take-home pay of US workers and has probably been a major contributor to our prosperity, but it has been achieved by applying market pressures to a system that had excess capacity. Buyers of health care, large employers, commercial insurers and government are able to bargain for the lowest possible prices. As a result, there has been a decrease of more than 325,000 hospital beds and 850 hospitals in the past 15 years. Yet only 16 percent of all hospital beds are filled. Further shrinkage of hospital capacity is sure to come. As with all major social change, there was a price to pay for even this modest period of medical cost containment, with US spending still far in excess of other countries'. |
The public is increasingly suspicious of conflicts of interest between health care providers and doctors, and media reports are filled with stories of patients who feel they were denied necessary care. The reputation of the managed care industry plummeted to just above that of the tobacco industry, despite objective analysis showing managed care to be as good, if not better than traditional fee-for-service. Previously, antiregulatory, conservative politicians felt compelled to mandate certain benefits for managed care subscribers, particularly women. The morale of doctors and nurses is lower than it has been for decades. |
Future health care predictions
What lessons does the recent US experience hold for health care in the next century? We should expect an increased public appetite for more health care. The news media extensively feature promises of new therapeutic breakthroughs, carrying explicit and implicit suggestions of better health through more medical care. Over a decade ago I compared health care expectations in our country with five English-speaking countries. When the elderly were asked if, given a fatal diagnosis, they would seek a second opinion, the English response was, "Well, love, it's been a good life, let's have a cup of tea. It's all over." In the US, not only would they get a second opinion, a lot of them would probably find a lawyer. |
To explore the discrepancy between promise and performance, the Harvard School of Public Health has reviewed a host of clinical preventive services to identify those that will produce significant gains in population health. They found only five. Hormone replacement therapy in post-hysterectomy 50-year-old women can yield a 13 percent increase in life. More recent data linking estrogen therapy to increased heart disease might cause that to change. Treatment of severe diastolic hypertension at age 35 extends life by 64 months for a man, 68 months for a woman. Stopping smoking at 35 adds another two to two and a half years. Weight reduction in the obese gives almost a year to a year and a half. Exercise in a 35-year-old adds half a year for a man, nothing for a woman. All the studied factors, including Pap smears, mammograms and immunizations, didn't add more than a few days. They may have been helpful in selective patients, but not in the entire population. |
All signs point to a renewed growth of health care expenditures, although probably not at the previous steep level. This will result from the potent combination of an aging population with increasingly prevalent chronic conditions; the avidity with which we all will pursue services to improve health, appearance and vigor; and the continued development of new drugs and technologies that promise to postpone or avoid disability and even death. While there are a small number of services that are both cost-effective and healthful, like immunization and prenatal care, recent medical history teaches us that almost all new technologies increase overall medical costs. |
Because of rising public expectations, it will become increasingly difficult to agree on what constitutes a basic minimal benefit package for which public or privately insured customers are eligible. The political temptation will be to create a broad package and seek ways to ration services in order to keep costs down. But as new information technologies like the Internet create more active and educated consumers, rationing will become less palatable, even in countries like England that are characterized by stoic, often passive patients. |
Thus, the tension between the desire to provide more health care services while simultaneously holding costs in check will probably be played out at individual clinical sites. This is because, in a political struggle between patients and providers, patients are going to win. Cost-containment strategies are liable to be seen as cuts in payment rates for hospitals and doctors, as well as the devolution of rationing decisions to individual clinicians. So the days of the hassle factor are going to stay with us. |
The future approach to health and health care
How can we modify personal behavior toward healthy habits? In my view, there are two streams of effort that should be undertaken in parallel. The first is to increase scientific research on prevention. Though impressive gains have been made in our knowledge about the determinants of human behavior, there is much more to learn. Compared with the seductiveness and relative freedom in basic science, behavioral research often ranks second in the contests for resources and the best minds. |
Even if we triple spending on basic biomedical research and the NIH builds palaces all over the Washington area, we will find ourselves disappointed by the difficulty of improving our nation's health. Only by improving both our scientific knowledge of health behavior and our understanding of social marketing can we achieve meaningful improvements in health. We need to improve translating knowledge into action. We can learn from the commercial worlds of marketing and communication and successful citizen action campaigns like Mothers Against Drunk Driving. |
Florida conducted an aggressive tobacco advertising campaign against youth smoking, and in two years smoking among middle-school students decreased an incredible 54 percent. This is a revolutionary decline that the American Legacy Foundation is trying to replicate nationally. Ad campaigns are too frequently stalled because the media is afraid of alienating their tobacco advertisers. Alcohol is trickier. While in tobacco we advocate abstinence, people who have one to two drinks a day are actually healthier than those who don't. |
Citizens have to make the National Institutes of Health (NIH) accountable for improvements in health status. Though the breast cancer lobby, the mental health lobby and the AIDS lobby are terrific, there is no anti-tobacco lobby. There is no organized group of people who have lost loved ones to tobacco. There are no real pressure groups addressing alcohol or drugs. There is no core citizens' group of public health. We cannot sit here, secure in our science, assuming that right will ultimately triumph. We must understand that health care and research is a political process, susceptible to political pressures. |
 | |
| Schroeder discusses disparities in lobbying for health care. | |
Meanwhile, there are 11 million kids in this country who don't have health insurance. Five and a half to 6 million of them are eligible for government insurance programs but go without because of stubborn bureaucratics, fearful parents, ignorance of program availability and lack of attention from the upper and middle classes. Right now the political focus is on drug coverage for the elderly and more benefits for the middle class, and the poor are mostly forgotten. The flip side of entrepreneurialism in this country is a lack of solidarity. My hope is that the public will eventually say, "It is morally wrong for a country this wealthy not to cover everyone with at least basic health care." |
At the level of the individual, patients are becoming better-informed consumers and will become more discerning in the quest for quality. This will force the medical care system to focus more on quality measurement and improvement. The response of physicians should be to lobby for more resources and to strive for efficiency in order to stretch a fixed budget. This will mean moving more care out of the hospital, finding ways to curtail overuse of services, looking for lower-cost treatments and looking to postpone or prevent expensive institutional care in hospitals and in nursing homes. |
Since there are limits to how much physicians can be squeezed in the name of cost containment, politicians will have to directly address the tensions between mutually contradictory public desires for more services, equity and a low tax burden. It is likely that this will be resolved by establishing a basic level of services to which everyone is entitled, and then requiring extra premiums, copayments or full payments for extra services, in particular services seen as enhancing lifestyle or performance, like Viagra. These will not be seen as mandatory unless powerful political forces can be marshaled on their behalf. |
For the homebound elderly or the disabled, there will be pressures to find volunteer services and to support family care in order to preserve individual choices for autonomy and to prevent the social cost of institutionalization. Similar pressures will focus on care at the end of life, where patients will want to maximize their chances of survival, minimize pain and suffering and be more in control of the kinds of services they receive. |
There is much promise contained within these challenges. Think of where we were at the turn of the twentieth century, when there were no antibiotics, when you were told that if you entered a hospital there was less than a 50 percent chance that your health would be improved by that encounter. It may be possible to move toward a world in which lifestyles are healthier, medical care is more efficient and of higher quality, and patients are better informed and better able to take advantage of the exciting scientific breakthroughs that are sure to come. To achieve this will require strong political and professional leaders, such as those at this institution, and the resolve to confront fundamental trade-offs and balance competing interests. I only hope that we will be up to that challenge. |
|
| |
