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

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


1
Health Care ReformWhats Public Health Got to
Do With It?
  • Jack Thompson
  • University of Washington School of Public Health
    and Community Medicine
  • Arizona Public Health Association Spring
    Conference
  • April 10, 2008

2
Points to Cover in the Next Hour
  • Discuss the connection between public health and
    health care reform
  • Present model criteria for analysis
  • Review the health care reform platforms of the
    presidential candidates
  • Summarize approaches and discuss options for
    future work

3
Socialized Medicine
  • A system of health care in which all health
    facilities are owned by the government. Doctors
    and other health care personnel work for the
    government and draw their salaries from the
    government.
  • We arent talking about that today
  • But there are examples of this in the American
    Health Care System.
  • The US Veterans Administration
  • The Armed Services

4
Single Payer
  • A system of health care that provides universal
    and comprehensive coverage, with the government
    as the insurer issuing the payments.
  • In single payer, the government would NOT be the
    primary provider of health care. It would just
    be the primary payer. There would still be
    freedom to choose doctors and other health care
    professionals, facilities, and services.
  • But more about that from Dr. Jarvis we wont be
    talking about that here, either.
  • It is not a characteristic of any active
    candidates approach to health care reform
    (depending on how you view the Nader candidacy)

5
Definitions I Will Use
  • Personal Health Services/Medical Care
  • Diagnosis and treatment of disease or provision
    of clinical preventive services to individuals or
    families in order to improve individual health
    status
  • Population-based Public Health Services
  • Interventions aimed at disease prevention and
    health promotion that affect an entire population
    and extend beyond medical treatment by targeting
    underlying risks

6
  • There is no better illustration of the dilemmas
    of rational policy making in America than in the
    field of healththe first obstacle to rationalism
    is defining the problem. Is our goal to have
    good health - that is, whether we live at all
    (infant mortality), how well we live (days lost
    to sickness), and how long we live (life spans
    and adult mortality)? Or is our goal to have
    good medical care - frequent visits to the
    doctor, well-equipped and accessible hospitals,
    and equal access to medical care by rich and poor
    alike?
  • Thomas Dye Understanding Public Policy

7
From The Future of the Publics Health in the
21st Century
  • Recommendation 18
  • Adequate population health cannot be achieved
    without making comprehensive and affordable
    health care available to every person residing in
    the United States. It is the responsibility of
    the federal government to lead a national effort
    to examine the options available to achieve
    stable health care coverage of individuals and
    families and to assure the implementation of
    plans to achieve that result.

8
The American Health Care System Is a MESS
  • Cost
  • U.S. health care costs per person are 75-250
    higher than any other developed nation
  • Access
  • 47 million Americans (16) are uninsured
  • The uninsured are less likely to get the care
    they need
  • Quality
  • Despite technology knowledge advantages, the
    quality of U.S. health care is mediocre at
    best

New England Journal of Medicine, 354(11), March
2006 (report on RAND Corp study, funded by Robert
Wood Johnson Foundation)
9
Non-Financial Access Barriers System Factors
  • system capacity/provider supply
  • poor coordination of services
  • lack of usual source/lack of continuity of care
  • inadequate tracking and outreach
  • provider communication/attitude
  • lack of childcare
  • lack of transportation
  • discrimination
  • cultural competency
  • convenience hours, sites, waiting times
  • bureaucratic complexity and unfriendliness
  • managed care/provider reimbursement incentives
  • Medicaid not accepted

10
Challenges in Assuring Access
  • Continued increases in medical costs
  • Insurers dropping higher-cost people
  • Continued erosion of private insurance coverage
  • Employment-based insurance excludes many
  • Retirees lose health benefits

11
Challenges in Assuring Access
  • Elimination of provider cost-shifting in
    competitive environment
  • Erosion of continuity of care in competitive
    managed care market
  • Threats to public hospitals
  • Disruption of safety net by market forces and
    decreasing public funds for health services
  • Increasing cost-shifting to consumers and
    employees
  • Growth of managed care may add additional access
    barriers for low-income populations

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

13
Need, Access
Other
Health Care
Disease
Factors
Cure, Care
14
Growing Health Care Costs
Other
Health Care
Disease
Factors
Cure, Care
Clinical Epidemiology, Health Care Evaluation,
Health Services Research, etc.
15
Social Environment
Genetic Endowment
Physical Environment
Individual Response -Behavior -Biology
Health Function
Health Care
Disease
Well-Being
Prosperity
16
Factors that Influence Health Status
Influence
National Health
Expenditures

1.2 Trillion
10 20 20 50
Sources Centers for Disease Control and
Prevention, University of California at San
Francisco, Institute for the Future. Reprinted
from Advances The Robert Wood Johnson Foundation
Quarterly Newsletter, 2000, Issue 1, supplement,
page 1
17
  • Committee on Assuring the Health of the Public in
    the 21st Century

18
Approach and rationale
A guide to thinking about the determinants of
population health
19
From The Future of the Publics Health in the
21st Century
  • Recommendation 18
  • Adequate population health cannot be achieved
    without making comprehensive and affordable
    health care available to every person residing in
    the United States. It is the responsibility of
    the federal government to lead a national effort
    to examine the options available to achieve
    stable health care coverage of individuals and
    families and to assure the implementation of
    plans to achieve that result.

20
From The Future of the Publics Health in the
21st Century
  • Recommendation 19
  • All public and privately funded insurance plans
    should include age-appropriate preventive
    services as recommended by the U.S. Preventive
    Services Task Force and provide evidence-based
    coverage of oral health, mental health, and
    substance abuse treatment services.

21
From The Future of the Publics Health in the
21st Century
  • Specific types of care that are important for
    population health
  • Clinical preventive services
  • Mental health care
  • Treatment for substance abuse
  • Oral health care

22
From The Future of the Publics Health in the
21st Century
  • Problems in Quality of Care
  • Two particular quality problems have special
    significance in terms of assuring the health of
    the population
  • Disparities in the quality of care provided to
    racial and ethnic minorities
  • Inadequate management of chronic diseases

23
APHA 14 Points on Universal Health Care Toward
a National Health Program for the United States
  • 1. Universal coverage for everyone in the
    United States.
  • 2. Comprehensive benefits including health
    maintenance, preventive, diagnostic,
    therapeutic, and rehabilitative services for all
    types of illnesses and health conditions.
  • 3. Elimination of financial barriers to care.
  • 4. Financing based on ability to pay.
  • 5. Organization and administration of health
    care through publicly-accountable mechanisms to
    assure maximum responsiveness to public needs,
    with a major role for federal, state, and local
    government health agencies.

24
APHA 14 Points on Universal Health Care Toward
a National Health Program for the United States
  • 6. Incentives and safeguards to assure effective
    and efficient organization of services and
    high-quality care.
  • 7. Fair payment to providers using mechanisms
    which encourage appropriate treatment by
    providers and appropriate utilization by
    consumers.
  • 8. Ongoing evaluation and planning to improve
    the delivery of health services with consumer
    and provider participation.
  • 9. Inclusion of disease prevention and health
    promotion programs.

25
APHA 14 Points on Universal Health Care Toward
a National Health Program for the United States
  • 10. Support of education and training programs
    for all health workers.
  • 11. Affirmative action programs in the training,
    employment, and promotion of health workers.
  • 12. Non-discrimination in the delivery of health
    services.
  • 13. Education of consumers about their health
    rights and responsibilities.
  • 14. Attention in the organization, staffing,
    delivery, and payment of care to the needs of
    all populations including those confronting
    geographic, physical, cultural, language, and
    other non-financial barriers to service.

26
From the Commonwealth Fund Commission on a High
Performance Health SystemPrinciples for Health
Insurance Reform
  • Access to Care
  • Provides equitable and comprehensive insurance
    for all
  • Insures the population in a way that leads to
    full and equitable participation
  • Provides a minimum, standard benefit floor for
    essential coverage with financial protection
  • Premiums, deductibles, and out-of-pocket costs
    are affordable relative to family income
  • Coverage is automatic and stable with seamless
    transitions to maintain enrollment
  • Provides a choice of health plans or care systems

27
From the Commonwealth Fund Commission on a High
Performance Health SystemPrinciples for Health
Insurance Reform
  • Quality, Efficiency, and Cost Control
  • Fosters efficiency by reducing complexity for
    patients and providers, and reducing transaction
    and administrative costs as a share of premiums
  • Works to improve health care quality and
    efficiency through administrative reforms,
    provider profiling and network design,
    utilization management, pay-for-performance
    payment models, and structures that encourage
    adherence to clinical guidelines
  • Minimizes dislocation people can maintain
    current coverage if desired
  • Is simple to administer
  • Health risks are pooled across broad groups and
    lifespans insurance practices designed to avoid
    individuals with poor health risks are eliminated
  • Has the potential to lower overall health care
    cost growth

28
From the Commonwealth Fund Commission on a High
Performance Health SystemPrinciples for Health
Insurance Reform
  • Financing
  • Financial commitment is necessary to achieve
    these principles
  • Financing should be adequate and fair, based on
    ability to pay, and should be the shared
    responsibility of federal and state governments,
    employers, individual households, and other
    stakeholders

29
Factors to Consider in Reviewing Candidate Health
Platforms or in Advocacy Work
  • IOM Recommendations
  • Population-related care coverage (preventive
    services, mental health, substance abuse, oral
    health)
  • Quality of care related to disparities and
    chronic disease
  • APHA 14 Points
  • Commonwealth Fund Principles
  • Linkages with income maintenance and education
  • Cost containment through system reform

30
2008 Presidential Candidates Approaches to Health
Care Reform
  • Tax Incentives for Individual Market Insurance
    (McCain)
  • Mixed Private-Public Group Insurance with Shared
    Responsibility for Financing (Clinton and Obama)
  • Public Insurance (Nader and Kucinich approach
    not a factor in current debates)

31
Clinton Health Plan
  • Require everyone to get health insurance,
    subsidized by employers and the government
  • Three components lowering costs, improving
    quality, insuring everyone
  • Pay for it by rolling back tax cuts for
    households earning over 250,000 and savings in
    the existing system
  • Addresses prevention and chronic disease
    management
  • Addresses disparities

32
Obama Health Plan
  • Require that all children have health insurance
    aims for universal coverage
  • Require employers to provide insurance or
    contribute to the cost (exempt smallest
    businesses and reimburse employers for
    catastrophic health costs).
  • Create purchasing pool with choice of competing
    private plans and one public plan like Medicare.
  • Expand Medicaid, State Childrens Health
    Insurance Program
  • Addresses prevention and chronic disease
    management and disparities

33
McCain Health Plan
  • For free-market, consumer-based system opposes
    mandate requiring everyone to obtain health
    insurance
  • Provide tax credits for insurance purchase
  • Has pledged affordable health care for every
    American without a tax increase
  • Addresses prevention and chronic disease
    management
  • Does not specifically address disparities

34
Features of Candidates Approaches to Health Care
Reform(from The Commonwealth Fund Commission on
a High Performance Health System)
35
Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
36
WASHINGTON HEALTH CARE COMMISSION FINAL REPORT
(11/30/92)
  • The health systemmust go beyond ensuring access
    to and controlling costs of medical care.
    Services we traditionally think of as medical
    care - those provided by physicians, hospitals,
    nursing homes, and dentists - are critical, but
    they are only part of the health system.
  • The Commission envisions a health system which
    integrates policies designed to improve both the
    health status of the entire population (public
    health) and that of individuals (personal
    health). This can be accomplished by combining a
    strengthened public health system with changes in
    the personal health services delivery system.
    This integration would result in an overall
    health system that protects and improves the
    health status of allresidents.

37
WASHINGTON HEALTH CARE COMMISSION FINAL REPORT
(11/30/92)
  • The Commission recommends ensuring universal
    access to a uniform set of health services.
    This includes a uniform benefits package of
    personal health services to be provided by
    certified health plans, and population-based,
    non-insured health services to be provided
    primarily through the public health system.
  • The uniform set of health services consists of
    all services to whichresidents are ensured
    access. The uniform set includes (1) an insured
    uniform benefits package comprised of personal
    health services provided by certified health
    plans, and (2) a variety of non-insured services
    provided primarily by the public health systems.
    The uniform set consists of three major
    components personal health services, core public
    health functions, and health system support.

38
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