Walking away from the Spanish Steps in Rome recently, I passed former Speaker Newt Gingrich (R-Ga.) and realized how times have changed. I mean, here we both were in Rome for Pentecost Sunday. Though times have changed, only the discussion on health care seems to be stuck in a conversation that began in the early 1990s. What is amusing is that many applaud themselves for their efforts to move the bad boys and girls of the health care world to work together. What I see is much of the same conversation we had all those years ago.
Rather than assuming that increases in health care spending mean the sky is falling, we need to have a national discussion about what is the right amount of our gross domestic product to spend to reflect our values as a nation. We cannot continue to accept the premise that there is more waste in health care than in any other sector and that we are spending too much on health care.
The policy journal Health Affairs recently pegged the percent of the U.S. economy accounted for by health care spending at 16.6 percent and projected that 10 years later this will grow to 20.3 percent of the nation’s gross domestic product. What few people realize is the percentage includes surprising items, like elective plastic surgery, research, teaching and so on.
In 1965, our country had a discussion about our values and health. We decided that older adults should have the security of health care, so we enacted Medicare. Would we ever go back on this commitment? Of course not. Medicare reflects our values as a country. It has become an enduring part of our national character. Just as in 1965, today we need a health care reform discussion that results in a uniquely American solution.
Our American value of fairness should move us to provide health care coverage to everyone in this country. In an American health care solution, all sectors — public and private — have a role to play. Public solutions such as Medicaid, State Children’s Health Insurance Program and Medicare, while not perfect, have worked and should be strengthened. Also, most people with employer-based insurance are happy with their coverage, and employers should be supported in continuing to provide insurance. At the same time, those who can afford insurance but choose not to purchase it and companies that could offer insurance but choose an extra margin of profit over employee well-being should be brought into the system. Again, it’s a matter of fairness.
There is the school of thought that we should abandon the mix of public and private payment systems and move to a single-payer system. While some people have pointed to better health indicators of other countries with single-payer systems, this is like comparing apples to oranges. Health care outcomes in many other countries are different because how people live is also different. For example, the national diet in many other countries reflects a healthier approach. At the same time, America has increasingly settled into a sedentary lifestyle compared to other countries that have much higher rates of walking and active lifestyles. These are factors that have nothing to do with a payment model of health care.
There are also factors of clean air and clean water that must inform our current debate. After all, it is only now that we know that some of the cleaning agents we use to purify water result in what the Environmental Protection Agency gently calls DBPs (disinfection byproducts) and that there are chemicals that once released tend to accumulate called PBTs (persistent bioaccumulative and toxic). According to the EPA, in addition to being toxic, PBTs “remain in the environment for long periods of time, are not readily destroyed, and build up or accumulate in body tissue.—
What needs to change in the United States is that our national expenditures on clean air and water, school lunches, food subsidies and infrastructure must reflect a national priority on health. When health is a priority, new parks and the opportunity they offer for walking and physical activity will be a priority over roads. The opposite occurred during the debate on the stimulus bill — there was no risk to funding new roads, but funds to build new parks were almost eliminated as an allowable expenditure for stimulus funding.
We also have work to do to bring clinical practice into the realities of 21st-century science. The 15-year lag between the bench and the bedside costs us lives and money. Health reform legislation should fix the fissures that are being created by the current spin on comparative effectiveness research. Priority setting in CER must be led by the consumers and providers such data are meant to inform.
Consumers need the best in new science, not an aggregation or assessment of old science. Given the reality of personalized or precision medicine paired with the lack of available comparative effectiveness data on nearly 70 percent of the U.S. population (women, Hispanics, African-Americans, Asian and Pacific Islanders, American Indians and Alaska Natives), it is crucial that health reform legislation limit the use of the CER. After all, choice in health is a fundamental value of the American system of care.
If we are going to achieve meaningful health care reform, it is going to require a new discussion of our values as a country. It is also going to require one of the least favorite things of Congress and voters, new taxes. However, if the discussion is honest and reform is based on American values of fairness, equity and compassion, we will agree to make that funding happen.
Just like seeing Newt was a surprise, perhaps the implementation of meaningful health care reform will also be a surprise.
Jane L. Delgado, Ph.D, is president and CEO of the National Alliance for Hispanic Health.