Leif Wellington Haase . a senior program officer and Health
Care Fellow at The Century Foundation, developed this
insightful list.
The Century
Foundation conducts public policy research and analyses of
economic, social, and foreign policy issues, including
inequality, retirement security, election reform, media
studies, homeland security, and international affairs. The
foundation produces books, reports, and other publications,
convenes task forces, and working groups and operates eight
informational Web sites. With offices in New York City and
Washington, D.C., The Century Foundation is nonprofit and
nonpartisan and was founded in 1919 by Edward A. Filene.
The Best
The
Bill & Melinda Gates Foundation,
which fights preventable disease in the developing world
and is bucking the obstacles to success. Since 2000,
The Gates Foundation has donated more than $6
billion to this cause—more than almost any single donor
country
and four times the annual budget of the World Health
Organization. Part of Gates’ 2005 commitment: $258
million to fight malaria, which infects 300 –500 million
people a year and kills around 1 million, mostly African
children. It’s admirable that Gates is tipping the
scales mildly on medical research funding—only about 10
percent of current dollars go toward research on
diseases that account for 90 percent of annual deaths
worldwide. Better yet, his example is prodding and
shaming nations and international organizations into
changing their priorities.
State-level policymakers who are pushing universal
health coverage.
As the cause languishes in Congress, legislators like
Governor Rod Blagojevich of Illinois, whose
Healthy Kids bill will cover all uninsured children
in the state, and members of the Vermont House of
Representatives, which voted for a universal health
coverage bill in April, are keeping the torch lit.
Take
Care New York. An ambitious, simple, and no-nonsense
Web site introduced by New York City Public Health
Commissioner Thomas Frieden to improve public health
citywide. Thanks to his education efforts and tough
anti-smoking legislation, the number of smokers in the
city has dropped by an estimated 200,000 over the past
three years. Governing magazine rightly
named Frieden one of its public officials of the year.
Minnesota hospital systems that have stopped gouging
uninsured patients.
One of the ongoing scandals of U.S. health care is that
uninsured patients frequently have to pay more than
patients covered by large insurers for the same
procedures. Then they get dunned by bill collectors as
they try to dig out of impossible financial holes. Under
an agreement with Minnesota Attorney General Mike Hatch,
this honor roll of hospitals—Allina, North Memorial,
Park Nicollet, and HealthEast Care—agreed
that uninsured patients with annual household incomes
not greater than $125,000 would pay no more than the
large insurer rate for their treatment.
The
Veteran’s Health Administration.
Just a few years ago, most VA hospitals were a
laughingstock and a disgrace. Now the VHA system is
leading the pack in comparison with other health
plans on health care performance measures. Moreover, the
VHA is at the forefront of efforts to introduce
lifesaving new technologies and reduce medical errors.
The
Patient Inform Web site. The news media tends breathlessly to report new medical
findings without any context—e.g. what kind of study,
who paid for it, how it compares to existing knowledge
in the field. This
Web site, co-sponsored by the American Cancer
Society, the American Diabetes Association, and the
American Heart Association, attempts to analyze key
medical findings in language suited to a lay public. It
also suggests how patients should interpret the data in
making their treatment decisions. Maybe the idea of
having a nation of informed medical consumers is a pipe
dream—but Patient Inform is on a noble quest to prove
the contrary.
Medicare’s pay-for-performance initiatives.
For the first time ever, Medicare will reduce payments
this year to hospitals that don’t report their
performance on a set of health quality measurements.
Pay-for-performance—which allows payers to reward or
penalize doctors and hospitals on their success in
meeting certain goals, such as meeting evidence-based
clinical standards or providing appropriate preventive
care—has been
slow to take root in many practices, hospitals, and
health plans. If Medicare’s
pay-for-performance initiatives are a harbinger of
things to come (along with
new standards called for by the Institute of
Medicine), this could change for the better.
U.S.
life expectancy reaches an historic high.
It’s
up to
almost 79
years. To be sure,
rising trends in obesity might tip this in the
opposite direction before long, but let’s toast success
while we can.
Presidential no-show. Twelve hundred policymakers and advocates for the
elderly came to Washington in December for the White
House Conference on Aging, which was meeting for the
fifth time since 1961. Despite the obvious salience of
aging issues—Medicare reform, long-term care, shortages
of geriatric doctors—President Bush chose not to address
his own conference, the first time ever for a sitting
president.
Docs on
the take? Needless to say, most physicians are ethical and
conscientious—but the commercialization of modern
medicine has sent many down the wrong path and put other
doctors on the defensive. There’s a rogue’s gallery of
unseemly behavior—possible conflicts of interest,
dubious clinical trials, and ghostwritten scientific
articles—here,
here, and
here, and in a
valuable book-length expose by Jerome Kassirer, the
former editor of the New England Journal of
Medicine.
Health
Savings Accounts (HSAs). These accounts, allowed by Congress in 2003, feature
tax-favored savings accounts along with a
high-deductible insurance policy. They are making modest
inroads in employer-based health plans and in individual
insurance markets. (Somewhere in the range of one
million Americans are enrolled now, up from under half a
million in September 2004.) While they are all the rage
among health policy consultants who are touting
“consumer-directed care,” HSAs are being terribly
oversold. To learn in more detail why HSAs are unlikely
to lower overall health care costs while quite possibly
undermining existing small-group insurance coverage,
read
here,
here, and
here.
Wal-Mart tells the unhealthy: don’t bother applying.
In an
instantly notorious internal memo presented to a
retreat of Wal-Mart’s board of directors, the company’s
executive vice-president for benefits recommended
discouraging unhealthy job applicants, and recruiting a
younger workforce, by arranging for “all jobs to include
some physical activity (e.g. all cashiers do some
cart-gathering).” To be fair, the memo as a whole less
indicts Wal-Mart but the logic of employer-provided
health care in general. Except for a sense of
paternalism, decency, loyalty, and fair play, why should
employers in a competitive market cross-subsidize the
health costs of older and sicker employees when they are
rationally competing for younger and healthier ones, for
whom health coverage is a selling point in choosing an
employer? And in fact Wal-Mart simultaneously introduced
a new low-premium, high-deductible plan featuring health
savings accounts that should appeal to younger,
healthier, and single workers. Bashing Wal-Mart is good
clean fun, but the core of the problem is the absence of
good universal health insurance coverage for all
Americans, young and old, healthy and sick (which
employers should help fund, but not offer directly).
Whose
moral hazard? Cervical cancer is diagnosed in about 10,000 U.S. women
each year and kills about 3700. Merck has developed a
vaccine for cervical cancer that targets the virus that
causes 7 in 10 cancers and has shown impressive results
in clinical trials. The company intends to apply to the
Food & Drug Administration by the end of 2005 for
permission to market the vaccine. (GlaxoSmithKline is
also developing a cervical cancer vaccine.) Amazingly,
the Family Research Council and other conservative
groups have
raised doubts about administering the vaccine to
children (where it would be the most effective) because
they fear that it will encourage promiscuity and
undermine their preferred message of sexual abstinence.
South
Carolina’s proposed Medicaid reforms. Trying to slow the rise in the state’s Medicaid costs,
Governor Mark Sanford proposed giving 850,000 low-income
South Carolinians personal health accounts that they
would use either to pay for a managed care plan or to
pay for “self-directed” care directly from providers.
Though this idea has been progressively scaled back in
response to
withering criticism, the basic premise of including
personal accounts in Medicaid simply doesn’t make sense.
Personal accounts have little or no track record and
private managed care plans haven't saved money for
Medicare. So why would you take the most vulnerable,
often least-educated, poorest Americans and make them
the unwilling subjects of an unproven experiment?
The
Medicare Drug Benefit. There’s a lot of potential for good here for low-income
Medicare beneficiaries, who get tremendous help under
the benefit with prescription drug costs. And it’s hard
to criticize the impressive efforts of government
officials, state and local volunteers, and private
insurers to make sense, on behalf of older Americans, of
this needlessly complicated benefit. But the early
sign-up numbers don’t seem to be impressive—including,
sadly, among low-income seniors and the disabled—and
there are
lots of minefields both structural and political
ahead. To paraphrase Yogi Berra, for the drug benefit,
it’s getting late early.
We note that the mayor of Biritiba Mirim, Brazil, has
passed a law that forbids the town’s residents, until
further notice, from dying. May you all have the same good
fortune! Happy New Year!