Highlights of a Forum: Health Care 20 Years From Now--Taking	 
Steps Today to Meet Tomorrow's Challenges (07-SEP-07,		 
GAO-07-1155SP). 						 
                                                                 
"Unless we fix our health care system--in both the public and	 
private sectors--rising health care costs will have severe,	 
adverse consequences for the federal budget as well as the U.S.  
economy in the future." This is one of the key messages that	 
Comptroller General David M. Walker has been delivering across	 
the country in town-hall style meetings, in speeches, and on	 
radio and television programs. Using another format to explore	 
issues with health care experts, Mr. Walker convened a forum at  
GAO on May 17, 2007. Attendees included health policy experts,	 
business leaders, and public officials selected for their subject
matter knowledge and representation of various perspectives.	 
Participants examined health care cost, access, and quality	 
challenges in discussion sessions led by distinguished economists
Robert Reischauer and Mark Pauly and other leading health care	 
authorities Carolyn Clancy and Suzanne Delbanco. Nationally known
health insurance expert Leonard Schaeffer served as the keynote  
lunchtime speaker. At the conclusion of the forum, participants  
were polled for their views on points raised during the 	 
discussions. The poll was conducted using electronic voting	 
technology that produced real-time, but confidential, results.	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-07-1155SP					        
    ACCNO:   A75850						        
  TITLE:     Highlights of a Forum: Health Care 20 Years From	      
Now--Taking Steps Today to Meet Tomorrow's Challenges		 
     DATE:   09/07/2007 
  SUBJECT:   Budget controllability				 
	     Cost analysis					 
	     Cost control					 
	     Health care cost control				 
	     Health care costs					 
	     Health care programs				 
	     Health care reform 				 
	     Health care services				 
	     Health insurance					 
	     Information technology				 
	     Medically uninsured				 
	     Performance measures				 
	     Standards (health care)				 
	     CG Forum						 

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GAO-07-1155SP

   

     * [1]Preface to the Proceedings
     * [2]Comptroller General's Introductory Presentation

          * [3]Discussion by Forum Participants

               * [4]More on Long-Term Fiscal Picture
               * [5]Observations on Appropriate Focus of Health Care Reform
                 Effo

     * [6]Session 1

          * [7]Discussion by Forum Participants

               * [8]Fragmented Delivery System, Acute-Care Focus
               * [9]Additional Observations on Health Care Spending Growth

          * [10]Relevant Propositions and Electronic Poll Results

     * [11]Session 2

          * [12]Discussion by Forum Participants

               * [13]Observations on Universal Coverage
               * [14]Defining Basic Benefits
               * [15]Potential Models for Expanding Coverage
               * [16]Coverage Solutions for a Heterogeneous Population

          * [17]Relevant Propositions and Electronic Poll Results

     * [18]Lunch Session
     * [19]Session 3

          * [20]Discussion by Forum Participants

               * [21]Setting National Goals
               * [22]Impact of Quality Improvements on Cost
               * [23]Public Reporting
               * [24]Limits of Health IT

          * [25]Relevant Propositions and Electronic Poll Results

     * [26]Wrap-Up

          * [27]Health Care Spending
          * [28]Health Insurance Coverage
          * [29]Technology
          * [30]Performance Measures
          * [31]Poll Results

     * [32]Appendix I: Forum Agenda
     * [33]Appendix II: Forum Presenters and Participants

          * [34]Forum Presenters

               * [35]Forum Participants
               * [36]GAO Forum Managers
               * [37]Order by Mail or Phone

     * [38]PDF6-Ordering Information.pdf

          * [39]Order by Mail or Phone

Health Care Forum Health Care Forum Health Care Forum Health Care Forum

Contents

Letter 1

Preface to the Proceedings 1
Comptroller General's Introductory Presentation - David M. Walker 4
Session 1: Cost and Personal Responsibility - Robert Reischauer 9
Session 2: Covering the Uninsured - Mark Pauly 14
Lunch Session: Breaking the Policy Impasse to Secure America's Future -
Leonard Schaeffer 18
Session 3: Quality, Standards, and Outcomes - Carolyn Clancy and Suzanne
Delbanco 20
Wrap-Up - David M. Walker 25
Appendix I Forum Agenda 30
Appendix II Forum Presenters and Participants 32

Table

Table 1: Results of the Health Care Forum Participant Poll 28

Figures

Figure 1: Revenues and Composition of Spending as a Share of GDP, Fiscal
Years 2006-2040 5
Figure 2: Social Security, Medicare, and Medicaid Spending as a Percent of
GDP, 2000-2080 6

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Preface to the Proceedings

As Comptroller General of the United States, I am afforded a mixed
blessing. On the one hand, I am burdened with T.M.I. ("too much
`'information") regarding the future of this country's federal fiscal
condition and outlook. I live each day with the knowledge and certainty
that unless we fix our health care system--in both the public and private
sectors--rising health care costs will have severe, adverse consequences
for the federal budget as well as the U.S. economy in the not too distant
future. On the other hand, my position and long tenure at GAO allow me to
bring the message to the public early and often. So far this year, I've
appeared on a number of major radio and television programs, including
NPR's Diane Rehm Show, CBS's 60 Minutes, and Comedy Central's Colbert
Report. Also, since 2005, I have traveled the country with the nonpartisan
Fiscal Wake-up Tour--a broad coalition of individuals and organizations
led by the Concord Coalition and involving the Brookings Institution, the
Heritage Foundation, and other organizations--to discuss the nation's
fiscal challenges in a series of town hall-style forums. Increasingly, and
disturbingly, my fiscal message has become a health care spending message.
In fact, health care costs represent the number one fiscal challenge for
federal and state governments and a major challenge to the competitiveness
of U.S. businesses.

I've used another format for shining a light on the challenge posed by
rising health care costs on the nation as a whole--two forums on health
care held at GAO, the most recent of which occurred on May 17, 2007. Our
discussions this year confirmed that little in the health care system has
changed since January 2004, when GAO held its first health care forum. Our
longer-range federal fiscal outlook, owing significantly to federal health
care entitlement spending, remains grim; Medicare and Medicaid spending
threaten to consume an untenable share of the national economy in the
coming decades. Health care spending systemwide continues to grow at an
unsustainable pace, eroding the ability of employers to provide coverage
to their workers and undercutting our competitive advantage. Finally,
despite spending far more of our economy on health care than other
nations, the United States has above average infant mortality, below
average life expectancy, and the largest percentage of uninsured
individuals. In short, our health care system is badly broken.

Nevertheless, I was encouraged to hear participants focus in a
constructive manner on a range of possible initiatives for health care
reform. Participants examined health care cost, access, and quality
challenges in detail. (See app. I for an agenda of forum sessions.) The
format was designed to maximize the opportunity for open, interactive
dialogue without individual attribution. Forum attendees included health
policy experts, business leaders, and public officials selected for their
subject matter expertise and representation of various perspectives. (See
app. II for a list of participants.) Distinguished economists and other
leading health care authorities served as leaders of the forum's three
discussion sessions and one served as the keynote lunchtime speaker. At
the end of the day, participants were polled for their views on several
key points raised during the forum regarding health care system challenges
and reforms.

These proceedings summarize the ideas and themes that emerged at the
forum, the collective discussion of participants, and comments received
from participants based on a draft copy. As such, these proceedings are
not intended to reflect the views of GAO. Their purpose is to serve as a
small step toward elevating public understanding of the challenge and
acceptance of the need for change. Ultimately, it will take the combined
efforts of many groups and individuals over an extended period to
successfully address the issue. Still, time is relatively short before
budgetary pressures end the chance for health experts to decide
deliberatively and thoughtfully on the future of the nation's health care
system.

I wish to thank all the forum participants for taking the time to share
their knowledge, insights, and perspectives. These will be of value to the
American people and to their representatives in Congress as they
communicate with their constituents about the inability of our health care
system to maintain the status quo. We at GAO will also benefit from these
insights as we carry out our mission to help Congress examine federal
health care spending and its implications for all health care payers. I am

hopeful that the American people will become fully engaged in national
debate on this topic as a means to facilitate serious, timely, and
sustained action that can help save our fiscal future for the benefit of
our country, children, and grandchildren.

David M. Walker
Comptroller General of the United States

Comptroller General's Introductory Presentation

Health Care Forum Introductory Presentation, led by David M. Walker,
Comptroller General of the United States. Mr. Walker opened the forum with
a presentation entitled "Health Care System Transformation Challenges: The
Need for Leadership, Transparency, and Accountability." The following are
highlights of Mr. Walker's presentation.

The federal government is on a "burning platform" and the status quo way
of doing business is unacceptable. Today is not the problem, tomorrow is.
Mr. Walker noted that the present value of the federal government's major
reported long-term "fiscal exposures"--the difference between what we have
promised and what we have in dedicated revenues--totaled over $50 trillion
in 2006. This represents close to four times gross domestic product (GDP)
in fiscal year 2006 and is up from about $20 trillion, or two times GDP in
2000. If we wanted to put aside today enough money to cover these
promises, it would take about $440,000 per American household, up from
$190,000 in 2000. Clearly, we have been moving in the wrong direction in
connection with our long-range imbalance in recent years. Equally
troubling are the long-range fiscal simulations by GAO and others showing
that, over the long term, the nation faces large and growing structural
deficits in future years due primarily to rising health care costs and
known demographic trends. (See fig. 1.)

Figure 1: Revenues and Composition of Spending as a Share of GDP, Fiscal
Years 2006-2040

Note: This simulation assumes that discretionary spending grows with GDP
after 2007 and all expiring tax provisions are extended through 2017.
Thereafter revenue returns to historical average of 18.3 percent of GDP
plus deferred revenue.

Absent significant changes on the spending or revenue sides of the budget
or both, these long-term deficits will encumber a growing share of federal
resources and test the capacity of current and future generations to
afford both today's and tomorrow's commitments. In particular, public
entitlement program obligations will be unsustainable for future
generations of Americans. As the baby-boom generation retires, federal
spending on current retirement and health care programs--Social Security,
Medicare, and Medicaid--will grow dramatically. A range of other federal
fiscal commitments, some explicit and some representing implicit public
expectations, also bind the nation's fiscal future. (See fig. 2.)

Figure 2: Social Security, Medicare, and Medicaid Spending as a Percent of
GDP, 2000-2080

Note: Social Security and Medicare projections based on the intermediate
assumptions of the 2007 Trustees' Reports. Medicaid projections based on
CBO's January 2007 short-term Medicaid estimates and CBO's December 2005
long-term Medicaid projections under midrange assumptions.

Absent policy changes, a growing imbalance between expected federal
spending and tax revenues will mean escalating and ultimately
unsustainable federal deficits and debt levels.

Mr. Walker observed that many of the federal government's current
policies, programs, functions, and activities are based on conditions that
existed decades ago, are not results-based, and are not well aligned with
21st century realities. Policymakers need to engage in a fundamental
review, reprioritization, and reengineering of the base of government.1
With regard to our health care system, specifically, the public needs to
be educated about the differences between wants, needs, affordability, and
sustainability at both the individual and aggregate level.

1See GAO, 21st Century Challenges: Reexamining the Base of the Federal
Government, [40]GAO-05-325SP (Washington, D.C.: Feb. 16, 2005).

Mr. Walker concluded that comprehensive health care reform will probably
need to occur in installments over a number of years. Our goals should be
fourfold:

           o Provide universal access to basic and essential health care.

           o Impose limits on federal spending for health care.

           o Implement national, evidence-based medical practice standards to
           improve quality, control costs, and reduce litigation risks.

           o Take steps to ensure that all Americans assume more personal
           responsibility and accountability for their own health and
           wellness.
			  
			  Discussion by Forum Participants

           After the presentation, forum participants asked questions related
           to Mr. Walker's illustrations of the long-term fiscal picture.
           Then the discussion broadened to participants' observations on the
           appropriate focus of health care reform efforts.
			  
			    More on Long-Term Fiscal Picture

           Some participants raised the following questions about the various
           assumptions underlying GAO's simulation in figure 1: How would
           allowing the tax cuts to expire affect the long-term fiscal
           picture? Would preventing an expansion of entitlements have a
           greater or lesser effect than eliminating the tax cuts?

           Mr. Walker responded that the recent tax cuts comprise only about
           1 percent of GDP; in a GAO simulation under which the tax
           provisions expire, the long-term fiscal imbalance remains largely
           unchanged. Not surprisingly, the entitlement programs are the
           bigger fiscal problem. In addition, not only must the federal
           government reform Social Security, Medicare, and Medicaid and
           institute tough budget controls, it must also engage in
           comprehensive tax reform that will not undercut our economic
           growth and must reprioritize and constrain other federal spending.
           Maintaining federal revenues at their historical average of 18.3
           percent of GDP will not be enough to cover the growth in the
           entitlement programs. We must do all of these things, and the
           sooner the better because time is working against us and our debt
           clock is ticking.

           Another participant asked whether GAO has created a scenario that
           assumes the growth rate for Medicare spending is kept to the
           growth rate of GDP or GDP plus 1 percent. Mr. Walker noted that
           GAO's simulations are based on data from the Medicare Trustees'
           "best estimate" (intermediate) projections, which assume that
           Medicare spending grows at a rate of GDP plus 1 percent. He added
           that that this growth rate pushes the fiscal imbalance problem
           further into the future but does not solve it.

           Yet another participant wondered how this message, which has been
           heard for several decades, might be different today. Mr. Walker
           explained the difference as follows: the traditional measures of
           fiscal health-- economic growth, inflation, interest rates,
           unemployment, and capital markets' performance--may not point to a
           current fiscal crisis. Nevertheless, the long-range structural
           deficit is worse today than it was in the 1980s and closer to
           becoming a reality. Furthermore, the political and social
           circumstances today are quite different from the 1990s. At that
           time, the United States was mostly borrowing from itself. Today
           our debt is increasingly held by foreign creditors who may put
           political pressure on the United States to change its policies in
           their favor. Another difference relates to the baby boom
           generation's impending retirements, which will result in an
           unprecedented strain on U.S. entitlement programs and therefore
           the federal budget. Finally, the geopolitical climate has changed
           such that there are new emerging superpowers, including China,
           India, and the European Union, competing with the United States in
           world markets.
			  
			    Observations on Appropriate Focus of Health Care Reform Efforts

           Several participants agreed that addressing problems in the health
           care system cannot be limited to the federal government's role.
           According to one participant, framing the issue is the most
           important factor in finding a solution. He contended that
           patients' experiences with the health care system should be the
           highest priority. Another participant countered that the federal
           role was most important, as Medicare, Medicaid, and the federal
           employees' health insurance program make government the largest
           payer in the health care system and federal payment models have
           had a strong influence on private payers. For example, in the
           1980s the movement in Medicare to pay hospitals prospectively
           based on groups of related services--that is, DRGs--rather than
           reimbursing them their charges was adopted eventually by payers
           systemwide.

           Several participants commented on elements they believed should be
           the focus of health care system reform, offering a diversity of
           views:

           o We are not getting good value for our dollars spent; health care
           quality needs improvement, as demonstrated by studies finding
           evidence of both overuse and underuse of services.

           o The problem with discussions about "reforming the system" is
           that we do not have a system to reform. Ours is a disaggregated
           model in which providers operate as individual self-interested
           entities seeking to maximize their revenue.

           o We should focus on the rate of health care spending growth and
           its driver, medical technology, rather than on system reforms.

           o Looking at individuals' out-of-pocket costs--that is,
           copayments, coinsurance, and deductibles--is highly misleading as
           a focus for reform. Under our third-party payer system, the true
           cost of health care remains hidden from view. In the private
           sector, prices are neither transparent nor uniform, as
           negotiations between payers and purchasers occur under cover.
           Therefore, the extent to which public and private payers are
           subsidizing one another remains unknown. We need to examine health
           care costs in their totality.

           Following Mr. Walker's remarks and group discussion, participants
           engaged in discussions on three major topics: health care costs
           and the role of personal responsibility; access to and coverage
           for health care services; and health care quality, standards, and
           outcomes. Session leaders began with a presentation of key points,
           after which discussion was opened to all participants.
			  
			    Observations on Appropriate Focus of Health Care Reform Efforts

           Cost and Personal Responsibility, led by Robert Reischauer, Urban
           Institute. To what extent or in what ways can federal health care
           spending be controlled? Should there be absolute spending limits,
           spending triggers, or spending targets? Should tax preferences be
           reformed and insurance incentives structured to foster personal
           responsibility? Dr. Reischauer developed several of these topics
           for discussion, as paraphrased here:

           Health care is the monster in the federal budget. Under certain,
           not unreasonable, assumptions about the rate at which health care
           costs are projected to grow, spending on Medicare and Medicaid
           will soar to unsustainable heights. However, "trends which are
           unsustainable will not continue." What can or should be done? Will
           policymakers address the health care spending trend in a timely
           and incremental fashion or will more drastic change be forced on
           us by crisis?

           Some argue for controlling federal health care entitlement
           spending--that is, spending on Medicare and Medicaid. The question
           is, can federal spending be controlled in isolation of spending in
           general? The American public will not tolerate separate health
           care systems for services provided though entitlement programs and
           those provided through the private sector.

           Proposals to control spending with absolute limits come with an
           array of policy questions. For example:

           o What would be the measure used to set a spending limit: a
           percent of GDP? a percentage growth rate? a percentage of the
           federal budget? a per capita dollar value?

           o How do you decide on the threshold number? What factors should
           affect the threshold--for example, population size? the
           population's health status? the general inflation rate?

           o How could you have a national limit when levels of spending,
           growth rates of spending, and quality of care vary across
           geographic areas? If Medicare spending in Minnesota is half of
           what Miami spends, why should the same steps be taken to control
           spending in both areas?

           o How do you enforce exceeded limits: reduce provider payment
           updates? increase beneficiary premiums? tighten program
           eligibility rules?

           Another way to control spending relies on incentives to slow
           growth--ranging from revising tax exclusions for insurance
           premiums and out-of-pocket costs to achieving greater price
           transparency. A third way involves discouraging unhealthy
           behaviors, by penalizing smokers and drinkers, for example, with
           higher insurance premiums.

           At the end of the day, however, can incentives to slow growth and
           penalties for unhealthy actions result in anything more than
           rearranging the Titanic's deck chairs? In particular, can federal
           health care spending really be controlled without fundamentally
           restructuring the nation's delivery and financing systems?
			  
			  Discussion by Forum Participants

           In response to Dr. Reischauer's presentation on taming health care
           spending growth, participants discussed the nature of the U.S.
           health care delivery system and efforts to address certain of its
           flaws. They also made observations about, among other things, the
           price of medical care in the United States relative to other
           countries and the role of medical technology in driving spending
           growth.
			  
			    Fragmented Delivery System, Acute-Care Focus

           The group generally agreed that our disconnected health care
           delivery system is not designed to treat, with efficiency,
           individuals with chronic conditions (e.g., diabetes, hypertension,
           asthma)--the population that accounts for most of health care
           spending. As one participant noted, "the entire system works fine
           in terms of short-term care, such as colds or broken arms, but
           works terribly in treating chronic conditions." Another noted that
           Medicare in particular was built around paying for a disease or
           injured body part. Payment under this approach has not fostered
           efficiency nor is it conducive to disease management or
           prevention. For example, physicians are financially rewarded for
           the number of services they provide while financially discouraged
           from time spent on care management and prevention. Related to that
           idea, some participants noted the importance of integration,
           meaning that doctors, hospitals, and other health care providers
           should be organized to provide care and receive reimbursement as
           integrated units. Without such integration, another participant
           pointed out, current pay-for-performance initiatives aimed at a
           single provider type will not achieve desired savings and will
           remain superficial; incentives to be efficient need to be aligned
           across all providers to foster cooperation. Pay-for-performance
           efforts aimed solely at hospitals, he continued, will not work
           while physicians are ordering 80 percent of health care services.

           Some in the group cited integrated care delivery, longitudinal
           care (as opposed to episodic, illness-oriented, complaint-based
           care), and built-in accountability for care as key factors needed
           to reform the current health care delivery system. Participants
           pointed to recent models that embody these factors, including:

           o the British and German health care models, where all specialists
           are employees of the hospitals, while primary care practitioners
           are out in the community.

           o provider-sponsored organizations (PSOs), which work much like a
           managed care HMO, except that they are formed by a group of
           hospitals and doctors who assume the financial risk of providing
           care to patients.

           o the medical home model, in which patients have direct access to
           one physician ("my personal physician") who accepts responsibility
           for managing their care, makes arrangements with teams of
           additional health professionals to provide services outside the
           practice's expertise, and is paid under a reimbursement system
           that rewards physicians and patients financially for choosing
           medical practices that foster quality and efficiency.

           o bundled payment systems, in which flat fees are paid for major
           procedures, such as coronary artery bypass surgery; these fees
           include some months of follow-up treatment and cover additional
           treatment if the patient suffers complications or is readmitted to
           the hospital.

           o Medicare's physician group practice demonstration, which tests a
           hybrid payment methodology that combines Medicare fee-for-service
           payments with a bonus that participating physicians can earn by
           demonstrating savings through better management of patient care
           and services and meeting quality performance targets.

           At various points in this discussion, several participants
           asserted that efforts to contain health care spending by federal
           payers--particularly Medicare--could not be effective if conducted
           in isolation from health care spending by private payers.
			  
			    Additional Observations on Health Care Spending Growth

           Some participants indicated that constraining capacity is a
           strategy that should be added to the list of reforms Dr.
           Reischauer presented. One explained that there has been a push to
           increase the number of physicians educated in our country, which,
           in leading to an increased number of physicians, could result in
           increased costs ranging from an estimated $5 billion to $50
           billion a year.

           Taking a different tack, another participant noted that the United
           States does not differ markedly from other countries in health
           care utilization, capacity, or technology. For example, she
           observed that the United States does not have more physicians per
           capita nor more hospital beds per capita than other countries and
           that Germany and Switzerland are also on the cutting edge of
           medical technology. The difference between our nation and others,
           she contended, is in price: in the United States, the payment
           level for services and for providers is higher than in other
           countries.

           With regard to health information technology (IT), one participant
           saw it as an important part of the solution to health care cost
           control. She gave an example of small businesses that have not had
           their health insurance premiums go up for 5 years because of their
           ability to use health IT to control costs. Several other
           participants noted the potential for health IT to improve the
           quality of care but believed that on a wide scale it would have
           little effect on cost, given the nature of major health care cost
           drivers.

           Several participants noted the major contribution of medical
           technology advances to rapid health care cost growth. The dilemma
           for society, contended one, was to balance the seemingly limitless
           potential to improve technology against the cost of doing so. The
           participant observed that technology could be vastly improved for
           automobiles, but people would not be willing to pay for it. He
           concluded that work needs to be done in the area of comparative
           effectiveness--that is, comparing the relative benefits and costs
           of drugs, medical devices, and medical procedures designed to
           achieve the same outcome.

           One participant suggested that a more fundamental problem existed
           than could be addressed by imposing spending limits, changing the
           health care tax exclusions, or encouraging better health habits
           nationwide. Citing noted economist Professor Uwe Reinhardt of
           Princeton University, he observed that our health care delivery
           system is like an elephant walking over trees and policy makers
           are tiny people hitting the elephant with sticks. In other words,
           the real problem--provider oligopolies (such as specialty
           hospitals that can self-refer) and unsavory relationships between
           physicians and drug companies and physicians and the research
           community--is massive and reforms to bring down health care
           spending do not address these complex and destructive
           relationships.
			  
			  Relevant Propositions and Electronic Poll Results

           The electronic poll conducted at the end of the forum asked for
           participants' views on points raised in session leaders'
           presentations or in the discussions following. Participants could
           strongly agree, agree, neither agree nor disagree, disagree, or
           strongly disagree with 18 propositions presented. Below are the
           poll results for the propositions related to points made in
           session 1. Using a two-part test for statistical significance, we
           sought to determine the extent to which participants agreed with
           each of 18 propositions. For a comprehensive look at the poll
           results, see pages 27-29.
			  
			  Session 2

           Covering the Uninsured, led by Mark Pauly, Wharton Business
           School, University of Pennsylvania. Should every American have at
           least some health insurance? If yes, why and how much? What, if
           any, federal role is there in ensuring some basic level of
           coverage to all Americans? Should the minimum coverage for
           different people be uniform for everyone or different for people
           at different income or health status levels? Dr. Pauly developed
           several of these topics for discussion, as paraphrased here:

           What do we know for sure about the uninsured population? Dr. Pauly
           identified some facts and conditions that health care experts
           generally agree on.

           o The uninsured population is a very heterogeneous group. Compared
           with the insured population, the uninsured population has a higher
           share of those who are nonworking, poor or near poor, or at high
           risk for health problems. However, many of the uninsured are
           working, not poor, and not at risk for serious health problems.

           o People are uninsured for different reasons: some because the
           cost of insurance is high relative to their total income and other
           basic needs, and others because the cost is high relative to the
           benefits they expect to receive, even though they may be able to
           "afford" it. This latter category includes young adults who do not
           expect to be in ill health.

           o From a policy standpoint, one of the most controversial
           uninsured subpopulations is the "Tweeners"--those individuals with
           incomes above the poverty level (up to 150 percent of poverty) but
           below the median income (about 325 to 350 percent of poverty).
           Three-fourths of the nation's Tweener population is insured,
           mostly through private insurance. Nevertheless, Tweeners make up
           about half of the uninsured population. With this blend of insured
           and uninsured in the Tweener population, policymakers are
           concerned with "crowd out"--which occurs when a public program
           attracts individuals who might otherwise obtain health insurance
           through the existing private market, thereby shifting health care
           costs to the public sector.

           o The current tax exclusion for employer-sponsored health benefits
           is inequitable and inefficient. Under this exclusion, an
           employee's health insurance benefits are not considered income and
           therefore not subject to income tax. Generally, people who can get
           health insurance through their employer thus get favorable tax
           treatment not available to others.

           o Being uninsured harms the health of those who are poor and near
           poor.

           Despite this general agreement regarding the uninsured population,
           Dr. Pauly continued, certain facts are in dispute. For one thing,
           research cannot quantify the existence or magnitude of harm to
           Tweeners of not being insured. There are correlations between
           insurance and health status, but correlation does not translate
           neatly into causation. Moreover, it is not clear that extensive
           coverage results in better health. While catastrophic coverage for
           the uninsured appears to be a good idea, research has not shown
           whether more generous coverage would have a significant positive
           effect on health.

           Similarly, the "distributional effect" of eliminating the tax
           exclusion of employment-based insurance is unknown. Specifically,
           to what extent would dropping the health insurance tax exclusion
           affect different population subgroups--the currently insured and
           uninsured--in terms of health coverage and health status? In a
           related point, Dr. Pauly noted that some proponents of coverage
           expansion advocate for uniform coverage for all Americans.
           However, uniform benefits for all is inefficient for producing
           equal access to care. Policies based on tax subsidy incentives,
           for example, should be targeted to low-income individuals if
           equity is to be achieved.

           Dr. Pauly concluded his presentation by noting that insurance
           coverage reform decisions will likely reflect societal and
           individual values, some of which are moral; others, more
           self-interested. Regardless of these differences, it appears that
           much of society is willing to incur costs to increase Americans'
           access to medical services, improve their health status, and
           reduce their chances of financial distress.
			  
			  Discussion by Forum Participants

           Following Dr. Pauly's presentation, participants examined issues
           associated with expanding health insurance coverage.
			  
			    Observations on Universal Coverage

           One participant called attention to the findings of a survey of
           the Citizen's Health Care Working Group--a 14-member body created
           by Congress and appointed by the Comptroller General. According to
           the survey, most citizens believe that all Americans should have
           access to health care coverage. The survey also found that most
           people are willing to share financial responsibility for extending
           coverage to the uninsured and providing financial security to
           protect individuals from medical bankruptcy.

           In reaction to the idea of universal coverage, participants made
           several points:

           o Caring for the uninsured now is costly; one participant put the
           cost at $126 billion annually, contending that an additional
           several billion dollars is spent in lost productivity because of
           uninsured workers' delay in treating health problems.

           o It is important to consider whether dollars spent now on the
           uninsured population's costs could be reinvested so that everyone
           had access to a core set of services and coverage for catastrophic
           health events.

           o The lack of political will to achieve universal coverage exists
           because of the absence of consensus on how to expand coverage and
           the peril politicians face when specifying the cost and details of
           a coverage expansion plan.
			  
			    Defining Basic Benefits

           A number of participants agreed that in considering policies to
           broaden health insurance coverage, it is not feasible to identify
           a "basic" or "minimum" benefit package. For example, one
           participant noted that "the search for a basic benefit package is
           akin to the search for the Holy Grail." Others pointed out that a
           consensus exists for considering only a small number of services,
           such as certain cosmetic surgery, as "luxury" medical care.
           Importantly, what is basic for someone with asthma or other
           chronic health condition may not be basic for a healthy
           individual. Further, one participant noted, regardless of what
           services are included, budget constraints are the most important
           factor in shaping any benefit package.
			  
			    Potential Models for Expanding Coverage

           Several participants noted that there are ways to proceed without
           trying to tackle the definition of a basic benefits package. One
           example is to expand catastrophic health insurance. Another
           participant noted existing programs that can serve as models for
           expanding health insurance, although with some qualifications:

           o Medicare is the most popular insurance program in the United
           States and should be considered as a potential model. At the same
           time, the benefit package is considered to be limited, lacking in
           stop-loss provisions, and most beneficiaries have additional
           insurance to supplement Medicare.

           o State Medicaid benefit packages often include a broad range of
           services and might be described as "generous," but because
           provider reimbursement levels are often very low, access to care
           often can be limited.

           o The Federal Employees Health Benefit Program (FEHBP) offers an
           array of options and choice to a sizable population across the
           United States. However, the population covered under FEHBP is
           employed and has reasonably good purchasing power. The
           cost-sharing requirements that are manageable for this population
           may not be equitable or affordable for the poor or near-poor
           populations.

           o The state of Oregon experimented with defining a core set of
           services as part of proposals to expand coverage statewide; but
           under public pressure, the core set broadened over time, which
           added to the proposals' cost.
			  
			    Coverage Solutions for a Heterogeneous Population

           Several participants noted that because the uninsured population
           is heterogeneous, there should be different solutions to
           increasing coverage for the different subpopulations. For example,
           one participant felt that public sector programs could be used to
           expand coverage for the poor and near poor while private sector
           plans could play more of a role in attracting those uninsured who
           have higher incomes. Another participant pointed out that
           requiring uniform health insurance coverage is inefficient because
           people have different preferences for the amount of coverage they
           are willing to pay for.

           Even under a pluralistic approach to expanding coverage, several
           participants noted that a dominant health care payer, such as
           Medicare, needs to be a larger player in the market. Otherwise,
           achievements in access to care, control of system costs, and
           widespread use of information technology and quality will likely
           be limited.
			  
			  Relevant Propositions and Electronic Poll Results

           The electronic poll conducted at the end of the forum asked for
           participants' views on points raised in session leaders'
           presentations or in the discussions following. Participants could
           strongly agree, agree, neither agree nor disagree, disagree, or
           strongly disagree with 18 propositions presented. Below are the
           poll results for the propositions related to points made in
           session 2. Using a two-part test for statistical significance, we
           sought to determine the extent to which participants agreed with
           each of 18 propositions. For a comprehensive look at the poll
           results, see pages 27-29.
			  
			  Lunch Session

           "Breaking the Policy Impasse to Secure America's Future," led by
           Leonard Schaeffer, founding chairman and CEO of WellPoint and
           former administrator of the Health Care Financing Administration.
           Mr. Schaeffer currently serves as Senior Advisor to TPG Capital.

           Mr. Schaeffer recapped several themes that emerged in two earlier
           sessions: the unsustainability of federal health entitlement
           spending, the demographic shift to an aging society that will
           consume more health care than ever, the lack of standard medical
           practices and evidence-based care, and the increasing burden on
           employers to finance health care. He followed with a discussion of
           barriers to implementing good policy, noting, among other things,
           that

           o physicians are not trained to manage the health care system;
           they function as individual contributors whose defense of their
           professional autonomy contributes significantly to a system
           lacking leadership and accountability;

           o consumers, spurred by advertising and the Internet, demand
           access to new medical technology, without knowledge of its value,
           safety, or efficacy;

           o information on price and quality, needed for the marketplace to
           work more effectively, is lacking on the major drivers of health
           care spending; and

           o advocating rational health policy is a "third rail" for
           politicians, as constituencies in health care are multiple and
           each has objectives that conflict with one another.

           Mr. Schaeffer contended that pragmatism rather than ideology
           should drive health policy. For example, proponents of a
           market-based strategy want to reform the insurance market and tax
           policies, rely on competition and consumer choice, and solve
           problems through increased use of information technology and
           greater price transparency. Alternatively, proponents of a
           regulatory strategy want to rely on government control of costs
           and spending, leverage federal programs, and establish best
           practices. Mr. Schaeffer argued for a blended strategy--one that
           coherently combines the best elements of the marketplace and
           regulation--to increase access, contain costs, and improve
           quality.

           Mr. Schaeffer concluded that a limited window of time--about 8 to
           10 years--remains for the health care community to engage in
           effective reform. After that, if nothing is done, federal health
           care spending will be at the mercy of budget hawks eager to lower
           the deficit. If the budgeteers are not successful, the national
           security experts will intervene, seeking to significantly reduce
           our debt to foreign nations whose interests and values may be
           contrary to ours. "We have to shape our future now or," he
           forecasted, "be its victim."

           Mr. Schaeffer sprinkled his presentation with candid commentary,
           some of which is highlighted below:

           Regarding reliance on consumerism to lower costs:

           o "American consumers don't have enough information in the health
           care market as opposed to other markets. To ask them to behave as
           good consumers is not reasonable."

           o "In the few cases where consumers have price information, they
           don't seem to comparison shop. If consumers don't price shop when
           it's entirely their health care dollar, why would they do it with
           other payers' money?"

           o "Do YOU have restless leg syndrome?" Who ever heard of it before
           the ad for the new drug? Consumers see ads, self-diagnose, and
           then go see their doctor."

           Regarding unmoderated growth in medical technology:

           o "Health care is one sector of the economy where the introduction
           of new technology does not replace the old, but adds to it."

           o "Health care technology diffuses on the 5 o'clock news. Every
           news station has a doctor now. Patients hear about new medicines
           before their doctors get a chance to read about them."

           Regarding health care reform solutions:

           o "This is an area of the American economy that is a significant
           risk to our economic future. Everyone who pays a bill is desperate
           for savings."

           o "Health information technology won't solve the problem. Health
           IT is required to collect data--then we have to turn data into
           information for decisionmaking and then make sane decisions."

           o "The best hope is to leverage federal Medicare and Medicaid by
           fiat, because the government can do things that other payers are
           afraid to do. It is not an easy position but the private sector
           will follow."

           o "It is not the market vs. government. We need a hybrid
           solution."
			  
			  Session 3

           Quality, Standards, and Outcomes, co-led by Carolyn Clancy, M.D.,
           Agency for Healthcare Research and Quality, and Suzanne Delbanco,
           The Leapfrog Group. How can national practice standards be
           developed to measure provider performance and what should be the
           federal role? How can IT facilitate quality measurement and
           improved outcomes? What do international comparisons of health
           outcomes and other such measures tell us about quality? The two
           session leaders discussed these and other issues in their
           respective presentations, which are merged here for purposes of
           exposition.

           The presenters raised several interrelated points on developing
           quality measures and addressing structural challenges. They noted
           that the need for improvement in health care quality is widely
           recognized. Studies confirm that a substantial gap exists between
           the best possible care and actual care. To illustrate that gap,
           experts estimate that providers do not "do the right thing"
           between 40 and 50 percent of the time. Not surprisingly, health
           care purchasers are increasingly monitoring the performance of
           their network providers. However, these monitoring initiatives are
           disparate and uncoordinated, lacking in an alignment of goals and
           consistency of measures nationwide. Part of the problem is
           structural, in that health plans, providers, consumers, and
           purchasers are all responsible, but no one is accountable. For
           example, about two-thirds of outpatient visits are to small group
           practices of fewer than five physicians. Because of their small
           size, there is not likely any one individual who is responsible
           for monitoring quality, while the infrastructure in small group
           practices--that is, the administrative resources to measure and
           monitor quality--is likely weak.

           What can be done in a system in which different stakeholders have
           diverse goals--that is, one seeks to reduce costs, another aims at
           ensuring error-free care, and others want to minimize
           administrative burden? The presenters offered these ideas and
           challenges:

           o The science of measurement is still evolving. Today's measures
           are tightly linked to site of care--for example, the physician's
           office, the hospital, or the rehabilitation center. This means
           that providers are blind to what happens when a patient leaves
           their enterprise. To date, measures that encompass episodes of
           care are not available, although researchers are working toward
           developing these measures.

           o With regard to the relevance of international comparisons, the
           Organization for Economic Cooperation and Development (OECD),
           which reports on health care quality indicators, concludes that no
           country does the best or worst on all measures, but some countries
           do better than others, and every country has areas of improvement.
           Similarly, within the United States, health care spending and
           outcomes can vary dramatically by geographic area. Although
           benchmarks should be set nationally, it is important to observe
           differences at the local level, since change is driven locally.

           o Finding a cohesive set of quality measures is a challenge. Some
           purchasers seek measures that can lead to improved quality care
           and reduced costs. The measures do not have to be perfect, as long
           as they improve on the current low level of information. To date,
           public agencies and private companies have organized under the
           National Quality Forum (NQF), a body created to promote a common
           approach to measuring health care quality.

           o In 2002, NQF sought to standardize adverse reporting by
           compiling a list of "never events"--safety errors that should
           never happen in a clinical setting but should be reported when
           they do. Since then, the list has been adopted or modified by
           other governmental entities and organizations. For example, the
           Leapfrog Group, an organization whose members include large public
           and private sector health care purchasers, asks hospitals to adopt
           the Group's own never events policy. This policy entails telling
           patients of errors, not billing the patient for care associated
           with the error, reporting the error as appropriate, and conducting
           a root cause analysis. Leapfrog is interested in the never events
           policy because it addresses cost and quality simultaneously.

           o In their search for standards, some purchasers are seeking
           health plans that, in their measurement initiatives, address the
           Institute of Medicine's six key traits of high-quality care--safe,
           timely, effective, equitable, efficient, and patient-centered.

           o How measurement information should be used--to reward
           performance or improvement--is another factor needing
           deliberation. One answer is to have incentives that not only
           reward "leading edge" providers but also bring along providers
           that are not at the top in performance.

           o Reporting to the public on physician and hospital performance
           matters. In fact, public reporting has been shown to lead to
           improvement in care. Whether the reporting should be voluntary or
           mandatory remains problematic, as drawbacks exist with both.
           Voluntary reporting may attract only those with nothing to hide,
           but mandatory reporting may suffer from trying to meet the needs
           of the lowest common denominator, which may not be sufficient to
           illuminate differences in quality among providers.

           o Public reporting is a "messy business." Purchasers are not
           consistent in the metrics they use to assess providers'
           performance, resulting in challenges in aggregating data across
           providers. The lack of uniformity adds to the difficulty of
           achieving transparency--making public the basis for reporting and
           the algorithms used.

           o Health IT is not a magic bullet to improve health care quality
           on its own. Rather, it can make the right thing to do the easy
           thing to do. The evidence that health IT saves money or results in
           improved quality is thin, as a substantial number of studies on
           health IT effectiveness are concentrated in four large
           institutions that had a strong champion inside the organization,
           ran home-grown health IT systems, and had lengthy experience with
           health IT. Less is known about the success of currently available
           commercial products.
			  
			  Discussion by Forum Participants

           Following the presentations by Dr. Clancy and Ms. Delbanco,
           participants elaborated on points the presenters raised, including
           national goal-setting, cost impact, public reporting, and health
           IT.
			  
			    Setting National Goals

           Participants reiterated the points raised by the presenters,
           noting in particular the importance of having national goals and
           benchmarks to define the performance expected from the health
           system. For example, some participants thought the collection and
           analysis of data should be done nationally; in deciding how to
           change practices, however, the scope of data analysis should be
           local to account for area differences: what works in one place may
           not in another. Others noted that no means exists for coordinating
           a national focus on quality. One participant thought the NQF could
           serve that coordinating function, but to do so would require more
           financial support, including federal resources. Another
           participant concurred that the efforts of NQF were good but
           questioned whether its consensus-driven model was bold enough for
           the level of reform needed.
			  
			    Impact of Quality Improvements on Cost

           Several participants were skeptical that quality improvements,
           desirable in and of themselves, would also save money. They argued
           that there was at best a weak relationship between quality and
           cost and that other actions would need to be taken to achieve cost
           savings. To illustrate, one participant noted that hospitals were
           unlikely to agree to forgo payments for certain never events, such
           as surgery on the wrong body part or a mismatched blood
           transfusion. As a result, while reducing avoidable never events
           could improve quality, different incentives would be needed to
           contain costs.
			  
			    Public Reporting

           Some participants identified the need to present quality
           information differently for consumers and professionals. For
           example, one noted, if we report that Hospital A has a 1 percent
           error rate and Hospital B has a 0.1 percent error rate, consumers
           shrug. But if we report that Hospital A's error rate is 10 times
           that of Hospital B, consumers react. We don't want to scare
           consumers, but we need to dramatize the issue for them. Another
           participant agreed that public reporting is not yet "consumer
           friendly." However, she also noted that consumers want information
           on quality and want the information when they actually get the
           care, according to survey findings released by The Commonwealth
           Fund. She reported that consumers have not had much impact on
           health care quality to date and need to get more involved. At the
           same time, health care systems must get better at making
           information more "actionable" for consumers.

           One participant cautioned that although we have some reasonable
           quality measures now (such as care for diabetes) and are
           developing more, some aspects of care may never be conducive to
           measurement or public reporting; instead, the attention should be
           placed on structural, payment, and organizational issues,
           including the need to create appropriate financial incentives and
           encourage stronger health IT to manage risk. Other participants
           countered that, although the current measures are not sufficient
           to drive change, improvements can happen as more measures are
           developed and reporting becomes more routine.

           In the end, one participant concluded, quality measures need to be
           driven by the "real world" of physicians practicing in their
           offices and doing what needs to be done medically, not just
           because the government is measuring it. Another participant
           suggested that Congress create a model system in each state that
           the local physicians could observe in operation to see how it
           could work for them. A third observed that most physicians view
           quality initiatives as "background noise," pointing to a key
           cultural challenge that needs to be met.
			  
			    Limits of Health IT

           Participants noted that if health IT is to be successful in
           affecting cost, quality, or both, a strong cultural change is
           needed systemwide, as well as alignment between the entity making
           the health IT investment and the savings achieved. Part of the
           cultural change includes assuring that the smallest unit in the
           health system has health IT capability. For example, Medicare's
           quality improvement organizations are working with small physician
           groups to implement health IT. Additionally, health IT investment
           may be more likely when cost savings accrue to the entity making
           the investment. For example, VA applied health IT to support the
           use of its cost-saving formulary. This positive impact was
           supported by an underlying structure of accountability within a
           closed system.
			  
			  Relevant Propositions and Electronic Poll Results

           The electronic poll conducted at the end of the forum asked for
           participants' views on points raised in session leaders'
           presentations or in the discussions following. Participants could
           strongly agree, agree, neither agree nor disagree, disagree, or
           strongly disagree with 18 propositions presented. Below are the
           poll results for the propositions related to points made in
           session 3. Using a two-part test for statistical significance, we
           sought to determine the extent to which participants agreed with
           each of 18 propositions. For a comprehensive look at the poll
           results, see pages 27-29.
			  
			  Wrap-Up

           In the forum's final session, Mr. Walker polled participants on
           their views regarding the health care system challenges and reform
           options that surfaced in the preceding sessions. Through the use
           of interactive voting technology, participants registered, on a
           5-point scale, the extent of their agreement or disagreement with
           18 propositions. (See table 1 at the end of this section listing
           each proposition and the polling results.) The technology allowed
           for the voting to be real-time but confidential.

           The poll was not intended to be scientific: our participant sample
           was neither random nor large enough to be statistically
           representative. However, forum managers, through careful
           development of the participant list, sought to ensure that the
           forum presentations, discussions, and poll results would not be
           biased in favor of any particular view of health system maladies
           or directions for reform.

           Taken as a whole, the poll results suggest several themes from
           participants' collective views on likely avenues for effective
           reform. The discussion below seeks to capture these themes,
           referring to the numbers of relevant propositions shown in table
           1.
			  
			  Health Care Spending

           The session discussions made it clear that nearly all participants
           felt some urgency about gaining control of health care spending in
           the United States. The group did not reach agreement about whether
           an aggregate spending limit, such as a percentage of the federal
           budget, should be used as a tool to control spending (#1) but
           strongly supported other measures, such as instituting value-based
           purchasing in federal health care programs (#5), changing the tax
           treatment of health care to encourage greater efficiency (#3), and
           limiting direct-to-consumer advertising of prescription drugs
           (#6). The group strongly supported encouraging individuals to
           assume greater responsibility for their health (#7) and generally
           agreed with permitting further importation of prescription drugs
           (#8) and aiming efficiency incentives at the individual patient
           (#2).
			  
			    Health Insurance Coverage

           Several of the themes emerging from the forum discussions and
           participant poll related to the role of the federal government in
           addressing health care challenges. In particular, despite the
           efforts of several states to reduce the ranks of the uninsured
           (#10), there was near unanimity among participants that ensuring
           the provision of health care coverage for all Americans should be
           a federal responsibility (#9). Further, the group agreed that the
           federal government should assure the existence of a
           well-functioning health insurance market (#12), whereas they
           reached no agreement on whether the nation should continue to rely
           on employer-provided insurance as the dominant method through
           which most Americans obtain their health insurance coverage (#11).
   
			  Technology

           In forum discussions and the participants' poll, participants
           generally favored constraining the development and diffusion of
           medical technology (#4). They strongly supported balancing the
           nation's research investments between new discovery and assessing
           the value of new and existing technologies (#18) and strongly
           favored the creation of a public-private entity to assess the
           comparative and cost effectiveness of health care products and
           services (#13). While discussions indicated that the diffusion of
           health IT was no panacea, there was strong support for government
           subsidy in this area (#16).
			  
			  Performance Measures

           Forum discussions generally supported the notion that reforms
           should be accompanied by the development of performance measures
           to gauge success or failure at meeting reform objectives. In the
           participants' poll, two-thirds of participants supported the view
           that OECD measures, which compare health system performance
           measures across countries, are a valid gauge of U.S. health system
           performance (#14), and four-fifths supported the federal
           government's taking the lead in developing new indicators of
           health system outcomes and performance (#15). Consistent with this
           view, the group also strongly favored the development of national
           practice standards by an independent body that includes key
           stakeholders (#17).
			  
			  Poll Results

           In conducting the participant poll, we sought to determine the
           extent to which participants agreed with each of 18 propositions,
           using a two-part test. First, we tested for the existence of a
           statistical difference (significance) between the responses of two
           groups--participants who said they agreed or strongly agreed and
           participants who said they disagreed or strongly disagreed. If the
           test did not find the difference to be statistically significant,
           we characterized the result as "no agreement." If the test found
           the difference to be significant, we conducted a further test to
           determine whether a statistically significant difference existed
           between the proportion of participants who agreed and the
           proportion of those who strongly agreed. If the test found a
           statistical difference, we characterized the result as "strong
           agreement." Otherwise, we characterized the result as "agreement."
           (See table 1.)

Table 1: Results of the Health Care Forum Participant Poll

Source: GAO analysis of health care forum participant poll.

Notes: Percentages may not add to 100 due to rounding.

aSignificance is at the .05 level (using a one-tailed test).

.

Appendix I: Forum Agenda

8:45 Welcome and Introduction: Bruce Steinwald--Director, Health Care
Team, GAO

8:50 Introductory Presentation and Group Discussion: David M.
Walker--Comptroller General of the United States

9:45 Session 1: Cost and Personal Responsibility: Robert
Reischauer--President, Urban Institute

To what extent or in what ways can federal health care spending be
controlled? Should there be absolute spending limits, spending triggers,
or spending targets? Should tax preferences be reformed and insurance
incentives structured to foster personal responsibility?

10:45 Break

11:00 Session 2: Access and Coverage: Mark Pauly--Professor of Health Care
Systems, Business and Public Policy, Wharton Business School

Should every American have at least some health insurance? If yes, why and
how much? What, if any, federal role is there in ensuring some basic level
of coverage to all Americans? Should the minimum coverage for different
people be uniform for everyone or different for people at different income
or health status levels?

12:00 Break

12:15 Luncheon: Leonard Schaeffer--Senior Advisor, TPG Capital; Founding
Chairman and CEO, WellPoint; Former Administrator, Health Care Financing
Administration

1:00 Session 3: Quality, Standards, and Outcomes: Carolyn
Clancy--Director, Agency for Healthcare Research and Quality--and Suzanne
Delbanco--CEO, The Leapfrog Group

How can national practice standards be developed to measure provider
performance and what should be the federal role? How can IT facilitate
quality measurement and improved outcomes? What do international
comparisons of health outcomes and other such measures tell us about
quality?

2:00 Session 4: Real-Time Poll of Forum Participants.

Use of interactive voting technology to assess the group's views on
long-term goals and promising first steps.

2:45 Wrap-up and Concluding Comments: David M. Walker--Comptroller General
of the United States

3:00 Adjourn

Appendix II: Forum Presenters and Participants

Forum Presenters

Carolyn Clancy Director, Agency for Healthcare Research and Quality

Suzanne Delbanco CEO, The Leapfrog Group

Mark Pauly Bendheim Professor of Health Care Systems, Wharton Business
School, University of Pennsylvania

Robert Reischauer President, The Urban Institute

Leonard Schaeffer Senior Advisor, TPG Capital; founding chairman and CEO
of WellPoint; former administrator of the Health Care Financing
Administration

David M. Walker Comptroller General of the United States

Forum Participants

Henry Aaron Senior Fellow, Economic Studies, The Brookings Institution

Robert Berenson Senior Fellow, The Urban Institute

Nancy Chockley President, National Institute for Health Care Management
Foundation

Nancy-Ann DeParle Managing Director, Healthcare, CCMP Capital

Elizabeth Docteur Deputy Head, Health Division, Organisation for Economic
Cooperation and Development

Elliott Fisher Professor of Medicine and Community and Family Medicine,
Dartmouth Medical School, Dartmouth College

Richard Frank Margaret T. Morris Professor of Health Economics, Harvard
Medical School, Harvard University

Anne Gauthier Senior Policy Director, Commission on a High Performance
Health System, The Commonwealth Fund

Gail Graham Director of Health Data and Informatics, Veterans Health
Administration, Department of Veterans Affairs

Robert Greenstein Executive Director, Center on Budget and Policy
Priorities

Mary Kay Henry International Executive Vice President, Service Employees
International Union

John Iglehart Founding Editor, Health Affairs

Karen Ignagni President and CEO, America's Health Insurance Plans

The Honorable Nancy Johnson Fellow, Institute of Politics, John F. Kennedy
School of Government, Harvard University

Randy Johnson Director of Human Resources Strategic Initiatives, Motorola,
Inc.

Charles "Chip" Kahn President, Federation of American Hospitals

Marjorie Kanof Managing Director, Health Care Team, GAO

Herb Kuhn Acting Deputy Administrator, Centers for Medicare & Medicaid
Services

Patricia Maryland Chair, Citizens' Health Care Working Group

Mark Miller Executive Director, Medicare Payment Advisory Commission

Ron Pollack Executive Director, Families USA

John Rother Group Executive Officer of Policy and Strategy, AARP

Dallas Salisbury President and CEO, Employee Benefit Research Institute

Henry Simmons President, National Coalition on Health Care

Bruce Steinwald Director, Health Care Team, GAO

Richard Umbdenstock President and CEO, American Hospital Association

Bruce Vavrichek Assistant Director for Health and Human Resources,
Congressional Budget Office

Alan Weil Executive Director, National Academy for State Health Policy

David Wennberg President and Chief Operating Officer, Health Dialog
Analytic Solutions

GAO Forum Managers

Jessica Farb

Hannah Fein

Mary Giffin

Bruce Steinwald

(290645)

Health Care 20 Years From Now

Taking Steps Today to Meet Tomorrow's Challenges

September 2007

GAO-07-1155SP

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www.gao.gov/cgi-bin/getrpt? [47]GAO-07-1155SP .

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Highlights of GAO-07-1155SP, a GAO forum.

HEALTH CARE 20 YEARS FROM NOW

Taking Steps Today to Meet Tomorrow's Challenges

September 2007

"Unless we fix our health care system--in both the public and private
sectors--rising health care costs will have severe, adverse consequences
for the federal budget as well as the U.S. economy in the future." This is
one of the key messages that Comptroller General David M. Walker has been
delivering across the country in town-hall style meetings, in speeches,
and on radio and television programs.

Using another format to explore issues with health care experts, Mr.
Walker convened a forum at GAO on May 17, 2007. Attendees included health
policy experts, business leaders, and public officials selected for their
subject matter knowledge and representation of various perspectives.

Participants examined health care cost, access, and quality challenges in
discussion sessions led by distinguished economists Robert Reischauer  and
Mark Pauly and other leading health care authorities Carolyn Clancy and
Suzanne Delbanco. Nationally known health insurance expert Leonard
Schaeffer served as the keynote lunchtime speaker. At the conclusion of
the forum, participants were polled for their views on points raised
during the discussions. The poll was conducted using electronic voting
technology that produced real-time, but confidential, results.

The discussion sessions focused on three interrelated topics: cost and
personal responsibility; coverage of the uninsured; and quality,
standards, and outcomes. The keynote speech focused on related policy
challenges. The following are highlights from these discussions and the
participant poll. The proceedings are not intended to reflect the views of
GAO.

Health care spending. Participants did not reach agreement on whether the
federal government should have an aggregate  spending limit, such as a
percentage of the federal budget, but supported other measures, such as
federal value-based purchasing, reformed tax treatment of health care, and
limits on direct-to-consumer advertising of prescription drugs.

Health insurance coverage. There was near unanimity that ensuring the
provision of health care coverage for all Americans should be a federal
responsibility. The group also strongly agreed that the federal government
should assure the existence of a well-functioning health insurance market,
whereas they did not agree on whether the nation should continue to rely
on employer-provided insurance as the dominant method through which most
Americans obtain their health insurance coverage.

Performance measures. Participants strongly supported the federal
government's taking the lead in developing new indicators of health system
outcomes and performance. The group also strongly favored having a
broad-based independent body develop national, evidence-based practice
standards.

Policy challenges. The keynote speaker opined that a limited window of
time--about 8 to 10 years--remains for the health care community to engage
in effective reform. After that, he noted, budget and national security
concerns will dominate. Because neither purely regulatory nor purely
market-based approaches are politically viable, pragmatism rather than
ideology should drive health policy. He concluded that we need a blended
strategy, stating, "We have to shape our future now or be its victim."

The figure below shows results for a sample of the 18 propositions that
participants were polled on at the end of the forum.

Selected Results of the Health Care Forum Participant Poll

Source: GAO analysis of health care forum participant poll.

References

Visible links
  40. http://www.gao.gov/cgi-bin/getrpt?GAO-05-325SP
  41. http://www.gao.gov/
  42. http://www.gao.gov/
  43. http://www.gao.gov/fraudnet/fraudnet.htm
  44. mailto:[email protected]
  45. mailto:[email protected]
  46. mailto:[email protected]
  47. http://www.gao.gov/cgi-bin/getrpt?GAO-07-438SP
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