[Congressional Record Volume 150, Number 50 (Monday, April 19, 2004)]
[Senate]
[Pages S4088-S4092]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
NOW CAN WE TALK ABOUT HEALTH CARE
Mr. DASCHLE. Madam President, yesterday's New York Times Magazine
contained a very insightful article written by our colleague from New
York, Senator Clinton. This article, entitled ``Now Can We Talk About
Health Care?,'' is truly a call to action.
Senator Clinton could not be more right when she points out that if
we were starting from scratch in designing a health care system, ``none
of us, from dyed-in-the-wool liberals to rock-solid conservatives,
would fashion the kind of health care system America has inherited.''
She pointedly asks why we should carry this flawed system and its
problems into the future. It is a rhetorical question, of course, but
the answer, unfortunately, is that we are doing just that.
Last year, 43.6 million Americans were without health coverage--an
increase of over 2 million from the year before. About 74,800 people in
my State of South Dakota--12 percent of the population--are without
health insurance. But statistics alone do not communicate the anguish
felt by so many people in our country regarding an issue as personal as
their health care.
Senator Clinton correctly notes that things will only get worse. Her
article explains that the very manner in which 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 care to the uninsured and underinsured
but also undermine the capacity of the system to care for even the well
insured.'' This a sobering warning.
It does not have to be this way. The United States is the only major
industrialized nation that fails to provide guaranteed health care to
all its citizens. And, in many countries--Canada, the United Kingdom,
Japan, France, and Sweden to name a few--they do it while spending less
per capita than we do in the United States. Yet in each of those
countries, citizens have greater life expectancies and lower rates of
child mortality than we have in the United States.
We must act. The nonpartisan Institute of Medicine recently
recommended that by 2010, everyone in the United States should be
insured. That is no small task, and it won't come free. But, as Senator
Clinton points out, it will save us money in other ways. People will
get the preventive care they need and deserve, and this will save us
the cost of treating conditions and diseases that have progressed. And,
certainly, it is a moral imperative when we are talking about people's
health.
We must invest in our public health infrastructure, in preventive
care, and in covering the care people need. We can save money by
increasing our reliance on information technology with appropriate
privacy protections. And we can use every tool we have--including
genetic testing--to prevent and contain disease. We can encourage these
tests by enacting the Genetic Information Nondiscrimination Act, a
bipartisan bill that has already passed the Senate but awaits action in
the House. We can reduce health disparities by passing the Healthcare
Equality and Accountability Act, a bill I introduced with each of the
House minority caucuses last year. And we can address the problem of
the uninsured in a serious manner rather than proposing tax credits
that will do little to help those most in need or pushing consumer-
driven plans that shift cost and risk onto the individual.
I commend Senator Clinton on her thoughtful article. It is something
we
[[Page S4089]]
all should read. Health care should not be a partisan issue. It is a
necessity. Whether someone receives the health care they need should
not depend on whether they are fortunate enough to access and afford
adequate health insurance under our current system. I ask unanimous
consent that Senator Clinton's article be printed in the Record.
There being no objection, the material was ordered to be printed in
the Record, as follows:
[From the New York Times, Apr. 18, 2004]
Now Can We Talk About Health Care?
(By Hillary Rodham Clinton)
I know that 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 generic 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?
21st-century problems
At the dawn of the last century, America was coping with
the effects of the industrial revolution--crowded living
conditions, dangerous workplaces, inadequate sanitation and
infrastructure in cities and pollution and infectious
diseases like typhoid fever and cholera that exacted a huge
toll on the oldest and youngest in society.
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.
medical advances
The pace of scientific development in medicine is so rapid
that the next hundred years is likely to be called the
Century of the Life Sciences. We have mapped the human genome
and seen the birth of the burgeoning field of genomics,
offering the opportunity to pinpoint and modify the genes
responsible for a whole host of conditions. Scientists are
exploring whether nanotechnology can target drugs to diseased
tissues or implant sensors to detect disease in its earliest
forms. We can look forward to ``designer drugs'' tailored to
individual genetic profiles. But the advances we herald carry
challenges and costs.
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.
Globalization
The globalization of our economy has changed everything
from how we work as individuals to what we produce as a
nation to how quickly diseases can spread. American
companies--and workers--compete not only with one another but
all over the world. It is called competitive advantage, but
it can put American businesses and workers at a disadvantage.
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
[[Page S4090]]
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.
Lifestyle and Demographic Changes
One hundred years ago, who could have predicted that living
longer would be a problem?
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.
old problems persist
If all we had to do was face these tremendous changes, that
would be daunting enough. But many of the systemic problems
we have struggled with for decades--like high costs and the
uninsured--are simply getting worse.
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 employees 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 insured 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 less than citizens in other advanced economies get.
how we deliver care
There is no ``one size fits all'' solution to our health
care problems, but there are common-sense solutions that call
for aggressive, creative and effective strategies as bold
in their approach as they are practical in their effect.
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.
harnessing modernization
As paradoxical as it is that advances in medical technology
could potentially break our antiquated system, advances in
other technologies may hold the answer to saving it. Using a
20th-century health care system to deal with 21st-century
problems is nowhere more true than in the failure to use
information technology.
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
[[Page S4091]]
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.)
taking the broader view: public health and prevention
While we focus on empowering the individual through
technology, we also have to recognize the larger factors that
affect our health--from the environment to public health.
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.
expanding coverage
All that we have learned in the last decade confirms that
our goal should continue to be what every other
industrialized nation has achieved--health care that's always
there for every citizen.
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 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 and 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
[[Page S4092]]
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 Senator John Kerry
has proposed, we should cover everyone living in poverty, and
all children; allow people to buy into the federal employee
health benefits program; and also help employers by
reinsuring high-cost claims while assuming more of the costs
from hard-pressed state and local governments.
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.
____________________