JIM LEHRER: And finally tonight, fixing the American health care system.
As most of you know, our health correspondent, Betty Ann Bowser, reported earlier this week on the major issues involved. They were also front and center today at a Senate confirmation hearing. Betty Ann again reports for our Health Unit, a partnership with the Robert Wood Johnson Foundation.
BETTY ANN BOWSER, NewsHour Correspondent: As the economy has worsened, President-elect Barack Obama has reinforced his promise that health care reform must remain near the top of his agenda.
Today, the man Obama wants in charge of that mission, Health and Human Services Secretary-designate Tom Daschle, said at his confirmation hearing that reform is not only necessary, it’s urgent.
TOM DASCHLE, Secretary of Health and Human Services-designate: The flaws in our health system are pervasive and corrosive. They threaten our health and economic security.
It is unacceptable that, in a nation of approximately 300 million people, nearly 1 in 6 Americans don’t have health insurance. As we face a harsh and deep recession, the problem of the uninsured is likely to grow.
BETTY ANN BOWSER: The former Senate majority leader got a warm reception from members of the Senate Health, Education, Labor and Pensions Committee, chaired by Sen. Ted Kennedy.
SEN. EDWARD KENNEDY (D), Massachusetts: Tom Daschle understands the urgency and the challenge of health reform. He knows that Americans feel the heavy weight of rising costs. He knows that families are afraid that they will lose their health insurance.
BETTY ANN BOWSER: If he’s confirmed, not only will Daschle be a cabinet secretary, he will also head a new White House Office of Health Reform. He laid out his vision of how the health care system should be changed.
TOM DASCHLE: I think we need to change the paradigm in this country on health. It starts with that big-picture belief that the paradigm needs to be changed from illness to wellness.
I look at health care as a pyramid, in every country, where, at the base of the pyramid, you have primary care, and you work your way up until you get more and more sophisticated, until at the very top you have heart transplants and MRIs.
Every country starts at the base of the pyramid with primary care, and they work their way up until the money runs out. We start at the top of the pyramid, and we work our way down until the money runs out. And the money runs out. And so few people get good primary care and wellness.
BETTY ANN BOWSER: Daschle discussed the litany of problems in the American health care system, including several addressed this week in our series.
The NewsHour team traveled to Tennessee, where people with insurance coverage are struggling economically; to Massachusetts, where there’s a shortage of doctors throughout the state; and to Kansas, where small businesses are coping with high insurance costs.
Daschle was asked about some of those issues: first, the shortage of primary care physicians.
TOM DASCHLE: Our system works through incentives. Right now, there’s a great deal of incentive to become a sub-specialist. I’d like to see the day when we incentivize in the same way our primary care providers, our nurses.
BETTY ANN BOWSER: Daschle also addressed the issue of the underinsured.
TOM DASCHLE: We have huge problems with regard to the number of uninsured, but that’s really the tip of the iceberg. We have a number of people who are so underinsured that today, we’re told, statistically you have about a 50-50 chance — if you’re insured — of getting the care that you need, 50-50.
BETTY ANN BOWSER: The secretary-designate also told the committee that it will cost the country more in the long run if nothing is done to reform health care.
TOM DASCHLE: We have serious cost problems now, but every expert says that, if we fail to address the issue of cost, that the situation will double just in the next 10 years alone.
BETTY ANN BOWSER: Daschle is expected to be confirmed by the full Senate after the Senate Finance Committee holds additional hearings.
Widening coverage, controlling cost
JIM LEHRER: And to Ray Suarez.
RAY SUAREZ: It's one thing to diagnose the problems of American health care. Fixing them is another matter.
We get some perspective on several of the issues we've examined this week and how to deal with them. It comes from Stuart Altman, professor of national health policy at Brandeis University. He's chaired government commissions tackling insurance issues. And he helped candidate Barack Obama design his health care plan, but he's not connected with the administration now.
Helen Darling is president of the National Business Group on Health. Her group represents more than 300 large employers.
Stuart Altman, we heard it from Tom Daschle today on the Hill. We heard it from ordinary Americans all during our series this week. Cost is a huge problem, whether you are insured and trying to keep your level of coverage high, whether you are not insured and trying to get health care, or whether you're a business trying to cover your own employees. Yet at the same time we've got 45 million uninsured.
Can we widen coverage, as President-elect Obama wants, without controlling cost?
STUART ALTMAN, Brandeis University: Well, I think we have to widen coverage. And I think, while I'm as strongly supportive of controlling spending as anybody, I do not want to make the uninsured hostage to us controlling costs. I think we need to do both.
I think what we did in Massachusetts was the right thing. First, we covered everyone. And now we are really seriously looking at it, how to control our spending.
I fear, if we put costs on the front burner, we will not cover the people we need to cover. So, yes, we need to control costs, but I don't want to make the uninsured the hostages for doing it.
RAY SUAREZ: Helen Darling, often in these debates when you start talking about cutting costs or even cutting the rate of growth, somebody finally pipes up and says, "Well, that means we have to say no to somebody." And that sharpens the debate still further.
HELEN DARLING, National Business Group on Health: Well, you don't have to necessarily say no to coverage and say a lot of people can't have any coverage. What you can do is use evidence and science to determine what is covered, what everybody gets, and make certain that we're not paying for things or people are getting coverage that doesn't do any good or even, in some instances, might be harmful.
RAY SUAREZ: Can we widen the health care net and stop the rate of increase of medical costs?
HELEN DARLING: Well, I think we have to do both simultaneously. We certainly shouldn't hold the uninsured hostage to controlling costs, but we have to control costs. So we have to do them both at the same time.
Primary care is essential focus
RAY SUAREZ: Stuart Altman, what are some of the ways that we can do that?
STUART ALTMAN: Well, first, let me support what Helen said. I think uppermost is the idea of putting a fair amount of government money into doing what we call comparative effectiveness, which is to sort of find out really what works and what works the best, as opposed to now, which former Sen. Daschle pointed out, we spend the most on the most complicated care, not necessarily on the care that does the best job.
So, yes, we need to focus on that. We do need to look hard at where we're using services. I don't want to call it waste, but where the value we're getting is not nearly close to the cost of the care.
I also support what Mr. Daschle said about primary care. Our system has a reverse pyramid. Where in other countries 50 percent of their physicians are in primary care, we're down to less than 20 percent.
But we're never going to solve that problem just with physicians. We need to bring more nurses into primary care. We need to bring other professionals, as well.
But at the end of the day, we have to change the delivery system. And in order to do that, we have to do away with the fee for service.
Right now we have a payment system that rewards doing as a -- as opposed to rewarding outcomes. If we don't change the payment system, we will never control costs.
RAY SUAREZ: Well, what would that look like? What would the alternative to fee for service be?
STUART ALTMAN: If we pay based on episode of care or bundled payments, where a deliverer got paid for providing high-quality care, not necessarily for doing the extra test or the extra operation, where they could pay for coordinators as opposed to doers.
We have in this country places that are doing it -- Geisinger in Pennsylvania, Kaiser in California, Intermountain in Utah -- and places even here, at our Partners HealthCare, why they're trying to do that. And what we need to do is make that available throughout the country. And in order to do it, we have to change the way we pay for care.
Information technology could help
RAY SUAREZ: Are there things in the tool kit, easy to understand, easy to follow for the millions who have to buy health care, that would help them understand how we're going to lower costs?
HELEN DARLING: Well, the most important and most dramatic step we could take right away -- and this would help enormously with the recovery -- is to invest in health information technology that -- and do the redesign, the business process redesigning that has to be done with the technology to make certain that we are increasing -- and we can do it dramatically -- increasing the productivity, safety, and quality of health care.
We could also use that information to help people to understand what's happening to them, for them to actually have the information they need to help manage their own care when they're at home and they need to take care of their own conditions.
And in addition, if you have information, then a lot of the errors that occur, the amount of excess testing, overuse of services that occur because a doctor may not have the information he or she needs at the time of a visit, really, millions of incidences go away with health information technology that get in the way of productivity, efficiency, effectiveness, and, of course, contribute very substantially to excess costs.
RAY SUAREZ: Now, at the outset, Helen Darling, we mentioned that your clients are big, big businesses, but you yourself run a small business. Is it hard getting coverage for your employees?
HELEN DARLING: Yes, and it's very expensive. And I have seen in the last seven years, every year, whereas the national average overall is about 6 percent increase or 8 percent, some place like that, for small employers it's considerably higher. It can be 11 percent, 12 percent, 13 percent, 14 percent, very much like your -- the people on the program in the other night said. It is much worse.
Small employers pay considerably more than large employers do on a per capita basis, and they have absolutely no purchasing power, so they can't negotiate. They can't make changes. There's a lot they can't do. So the small employer is in the worst condition.
But even so, even for the average, for a family in the United States today, it's $14,000. And with the median wage of about $42,000 before taxes, I mean, about a third of what people make in this country now goes just to health care.
And if it bought you nothing but perfect care and great health, maybe we could live with that. But it buys us an awful lot of services in some instances that don't make people healthier. They don't add value.
And many of the steps that Stuart mentioned, including better primary care and access to primary care, support for physicians, to pay them for the care coordination services they provide for patients and families, which we don't now pay for, so lots of things like that that we can do will save money, will contribute to the recovery, and improve the health of the American people.
Patient numbers overwhelm doctors
RAY SUAREZ: Stuart Altman, let's take a closer look at Massachusetts, which you brought up earlier in the conversation. When a new architecture was set up that allowed for wider care of the uninsured in Massachusetts, there was a sudden flood of new patients into primary care practices.
Some of them are unable to handle the demand for their services, yet there's a shortage of primary care physicians in the country. If we were to widen health care coverage, wouldn't every place be like Massachusetts?
STUART ALTMAN: Well, I don't want to say that we didn't have that problem. We had it particularly serious in our more rural areas. But, again, I wouldn't want us to hold back covering everybody because of this problem.
Most of the uninsured do get care, but they get it in the worst places. They wind up in emergency departments. They wind up waiting until they get very sick.
So, yes, we do have an issue with respect to primary care. And we need to deal with that right away. But I wouldn't want to even suggest that that ought to be an impediment to covering everybody.
RAY SUAREZ: Well, can we get more doctors to go in to primary care as their specialty?
STUART ALTMAN: Well, we've tried. I've been at this a long time. And we had plans as early as the mid-1970s. Yes, we can.
But to do that, we need, A, to encourage -- we need to change the way we pay. We need to be paying more to primary care. Right now, we pay so much more for subspecialty and specialty care it's really -- you know, any physician, any young person who takes on primary care is prepared to give up $100,000, $200,000 a year. So, A, we have to change the way we pay.
But it's going to take a long time. So I think the more immediately issue is for states to look at their labor market conditions about who can provide this care.
There are a lot of services that individuals other than physicians can provide, good, quality, primary care without having to have a physician.
RAY SUAREZ: Stuart Altman and Helen Darling, thank you both.