Chapter 4 Where Do We Want to Be?
Where Do We Want to Be?
Even in a country that lacks an overall, cohesive health policy, it is useful to ask: How unhappy are we with our health care, and what do we want to change? Do not expect consistent responses from the American public. When the nation was debating the Clinton health plan, a number of organizations surveyed the public. Respondents reported they believed that the health care system was in trouble. At the same time, they expressed satisfaction with their own largely employer-financed health care programs. Public support for universal coverage was strong, but individuals did not want to pay higher taxes to support it (Peterson, 1995). An ABC New/Washington Post poll in October 1993 showed the following (Schick, 1995):
• 51% of the public favored the Clinton health plan.
• 59% thought that it was better than the existing system.
• Only 19% thought that their care would get better under it, and 34% thought worse care would result.
• However, 57% were against tax increases to pay for it, whereas 40% would be willing to pay.
The American public also appears to be split over the Patient Protection and Affordable Care Act (ACA) as a whole. Data about opposition to the act can be misleading, with a significant portion of opposition coming from people who believe the ACA did not go far enough. They would prefer a public option, for example, or a single-payer system. Overall, the public is
negative about the individual mandate and the employer mandate, but is much in favor of the insurance changes that have been implemented. People are confused about the insurance exchange provisions of the act as well. An April 2013 tracking poll found that “about half the public says they do not have enough information about the health reform law to understand how it will impact their own family, a share that rises among the uninsured and low-income households” (Kaiser Family Foundation, 2013). The same poll reported that 42% of respondents did not know that the ACA was still the law of the land. Twelve percent believed it had been repealed by Congress, 7% believed it had been overturned by the Supreme Court, and 23% didn’t know whether it was still in effect or not.
Americans report being in good health more than any other OECD country. Their complaints are mostly about financial risks and to some extent access and waiting. A 2010 study of six developed countries showed that Americans were satisfied with their doctors and the availability of effective care, but were also more likely to report that the system needed to be completely rebuilt (Papanicolas, Cylus, & Smith, 2013).
4.1 Alignment with the Rest of Society
4.1 ALIGNMENT WITH THE REST OF SOCIETY
The democratic process is likely to generate many policy experiments as we cope with advancing technology, changing demographics, political pressures, and economic fluctuations. These experiments will continue to stir debate about the merits of the many delivery and payment alternatives available in the United States and elsewhere.
For professionals in leadership positions, this is an unpleasant reality that makes it much harder to plan and implement any institutional strategy. Even the most prestigious institutions are affected by these external drivers. For example, the Finnish national orthopedic hospital, the Orton Hospital in Helsinki, had to downsize and reach out to private-pay individuals when the Finnish federal government chose to decentralize its jointly financed government health care program and pass administration on to local governments (Masalin, 1994). These local governments then attempted to control the rising cost of health care by reducing referrals to central specialized hospitals. Orton Hospital was a national resource of high-quality care, but as the referral patterns of the country changed, it, too, had to change the way it functioned in order to survive.
There is no universal, monolithic “we” when it comes health policy. There are interest groups, each of which has a central point of view. Within each group are many individuals with some diversity of views. They may be willing to compromise on some issues, but not on others. In the United States, much progressive legislation has been built by reaching agreement on means rather than on ends.
What Do Providers Want?
Providers are aware of their responsibility to act in the best interests of their patients. They are also inculcated with the “first do no harm” dictum. Even among the “disinterested” parties, some care most about individuals, whereas others focus on populations. This is often a vexing problem for those clinicians who, although committed to the needs of individual patients, are also trained in statistical thinking and population-based approaches.
Provider professionals want professional autonomy, income stability and growth comparable with their peers, successful outcomes for their patients, a sense of mastery of their field, and the respect of the public. They know that they will make some mistakes, but they will work very hard to avoid them. They do not want to put their careers on the line with every decision. They do not want to waste energy on bureaucratic exercises that consume resources and distract them from effective care. They also would like to see provisions to pay for care for the uninsured. They are aware that these individuals often forgo normal care and may end up later with more serious and costly problems. That is why some hospitals and health maintenance organizations (HMOs) have strongly endorsed state plans to cover the uninsured, even when they involve adding a tax on their charges to paying patients.
The American Nurses Association (ANA) has expressed some of these desires in its Bill of Rights for Registered Nurses (ANA, 2014). It addresses not only working conditions for nurses but also the right to provide “services that maintain respect for human dignity and embrace the uniqueness of each patient and the nature of his or her health problems, without restriction with regard to social or economic status.” The document says nurses must have the ability to meet their obligations to society and their patients, as well as meet their own needs. In addition, they have a right to workplaces that allow them to meet professional standards, act within their scope of practice, perform their duties in accordance with the ANA code of ethics, advocate for themselves as well as their patients, be safe, keep their patients safe, and negotiate their conditions of employment.
The professional mystique of physicians in the past rested on their control of information. Those who favor a consumer-centric, free-market approach to health care decision making want to maximize the amount of information available to consumers. This has led many physicians to argue for privacy in the conduct of their practices, often in the name of protection of business secrets and personal privacy. Many physicians object, for example, to the fact that a drug company’s local sales representative has data on their prescribing behaviors (Saul, 2006). Insurers certainly profile physicians and institutions for costs and outcomes regularly, and aggregated data are increasingly available to employers, the National Committee for Quality Assurance (NCQA), the Joint Commission, the federal government, and the general public. The Centers for Medicare & Medicaid Services (CMS) released physician Medicaid income data in 2014.
Employer representatives want more information to be available to consumers. One thorny issue is information on individual physicians. President George W. Bush called for “transparency in the marketplace” and urged private insurers to disclose data on physician costs and outcomes; however, when the Business Roundtable called on the federal government to make its Medicare databases available, his administration cited a 1979 court ruling protecting the privacy of physicians and prohibiting disclosure of Medicare payments to individual physicians (Pear, 2006).
This is a difficult area. Professionals, like other businesspeople, have some rights to privacy and protections from the prying eyes of competitors, but some observers see the current tensions as the last gasp of a professional monopoly and an attempt to withhold information that bolsters purchaser sovereignty at all levels. Yet the public has difficulty interpreting this information effectively. Current techniques for evaluating case mix and adjusting for risk are crude at best. Measuring the outputs of medical interventions is difficult unless one knows that the inputs are comparable or unless there is a way to adjust the data to reflect differences in inputs, especially the condition of the patient going in.
Other professions fight to overcome the dominance of physicians. In many countries, pharmacists are freer to dispense independently. Nurse practitioners and midwives have fought state by state for the right to practice independently. Psychologists have been fighting some of the same battles with respect to prescribing for the mentally ill, and more and more types of counselors want to be able to bill Medicare, Medicaid, and private insurance.
What Do Patients and Their Families Want?
Patients want to beat the odds. They and their families want the best possible outcomes, and they want to know that everything possible was done to ensure recovery (or a comfortable death) for their loved ones. Some want miracles. All want respect and caring. Most know that they need experts to look after their interests, but still want to be kept informed of what is going on so they can make sense of what is happening and avoid serious medical errors. Again, the issues are complex. Patients and families want to have access to quality information if they have the time and energy to make their own decisions. At the same time, they employ the provider as their agent, and the sicker they are, the more they tend rely on the clinician’s judgment.
When they are not terribly sick, they also worry about the cost of their care. They do not want to spend a lot of time in the waiting room or figuring out how to fill out paperwork. That is a nonmonetary cost, but a cost to them, nevertheless. It can also be a monetary cost if they lose work hours or reimbursement opportunities because of it.
They want to know that they were not treated unfairly by any part of the health care system and that their treatment was not affected by their gender, their ethnicity, or the color of their skin. They would like to think that it was not affected by the capacity of their pocketbooks, but probably believe that to be a bit unrealistic.
They also become apprehensive when they believe that profitability concerns or payment mechanisms are influencing which treatments they receive. An example has been the debate over whether the drugs chosen by oncologists for outpatient treatment have been chosen for their effectiveness or their profitability (Abelson, 2006a; Jacobson et al., 2006). Increasingly, patients are aware of the financial incentives affecting providers that in the long run can undermine provider legitimacy (Schlesinger, 2002).
Before passage and early implementation of the ACA, a strong concern of individuals was that they did not want to be denied insurance on the basis of prior medical conditions over which they had little or no control. The ACA specifically prohibits denial of coverage because of preexisting conditions. This provision became effective at the start of 2014.
Some individuals, particularly those sometimes referred to as the “young immortals,” have been willing to “go bare” (not carry health insurance) if they perceive a relatively low probability of a significantly costly health care event. This has raised the issue of free riders getting emergency care, even though they are not making provision for paying for it ahead of time. This is part of the impetus for the ACA mandate that all individuals obtain health insurance or pay an income tax penalty. An even thornier problem has been the moral hazard of those who knowingly indulge in high-risk behaviors for which the general public has had to pick up a share of the costs. The primary rationale for mandatory helmet laws, for example, was not to protect motorcyclists; it was to shelter the public from incurring the tremendous ongoing costs of caring for people with serious brain damage.
Individuals also worry about being bankrupted when they have insufficient insurance coverage for current and future situations. The ACA has dealt with this is a number of ways, including barring lifetime caps on claims. Yet consumers also worry about what the premium costs will do to their disposable income. Again, the ACA tries to deal with that by subsidizing the premiums of low-income workers.
What Do Insurers Want?
Insurers want to stay in business. That is why they fought so hard against any hint of a single-payer system and against the Obama administration proposal for a government health plan that would appear in the exchanges alongside the existing product lines (the public option).
Insurers want to be free to play the odds. They want to be able to make an acceptable level of net revenue whether they are a for-profit or a non-profit organization. They want to be able to compete in the marketplace on a “level playing field.” Their customers are the payers—the employers and the group and individual enrollees—and they want to maintain a good reputation with them. In the world of HMOs and preferred provider organizations (PPOs), insurers want the biggest possible discounts from providers to keep their medical loss ratios competitive.
Insurers also want to avoid adverse selection. They want protection against having those who know they have a higher-than-average probability of a claim from joining their system in disproportionate numbers. They also want to be able to attract those with a below-average probability of a claim. They do not want to be in a situation in which they are disadvantaged vis-à-vis other insurers. They would like to continue to compete on marketing skills, on underwriting ability, on investment returns on their reserves, and on their operating efficiencies.
Insurers, however, are very sensitive to market shifts. For example, many are currently developing new insurance products for individuals and small groups as the notion of consumer-oriented care and insurance exchanges increase consumer involvement in choosing products (and as employers reduce their contributions and coverage). They suddenly seem interested in individual subscribers that they ignored a few years ago. They are also interested in offering self-insurance plans to the small employers that they ignored previously.
What Do Employers Want?
Employers want to be able to recruit and retain competent, productive employees, and they want competitive cost structures. They are not in the health care purchasing business for any other reason. They are generally supportive of consumer-driven health care that allows individual consumers, rather than employers, insurers, or provider organizations, to make more decisions than in the past. This effectively shifts more of the costs onto the employees and from the lowest paid employees onto Medicaid. With the exchanges and the play-or-pay provisions of the ACA, they have many more options to consider, and it will be interesting to see what options they gravitate toward and for how long. Because the ACA’s employer contribution provisions apply to employers with 50 or more full-time employees, and full time has been defined as an average of 30 hours per week or at least 130 hours in a month, employers may choose to reduce the hours of workers to below 30 hours per week to keep their employee head count below that threshold.
Large Employers and Unions
In unionized firms, premium payments are set through collective bargaining between the company and the union. This bargaining can expand or contract the health care benefits, depending on the wants and needs of the employer and key groups within the union. After a period during which many of our bitterest strikes were waged over health benefit issues, both sides are now recognizing that employment-related health care costs can reduce domestic employment by encouraging companies to shift production to other countries. Employers are rapidly limiting their liabilities to specific dollar contributions toward health care for employees and retirees. Large firms and their unions are increasingly aligned in their desire to hold down costs and maintain coverage.
Because health care insurance bargaining power can be increased by pooling large numbers of beneficiaries, and because administrative costs and insurance prices are very sensitive to the number of individuals covered, small businesses find it hard to provide competitive health benefits to their workers. They need either subsidies or effective ways of pooling their people with others to make a viable enrollee population. Accomplishing this has been a major thrust of the ACA, which includes premium subsidies for small firms.
What Do Governments Want?
They want a satisfied public. They want health care expenditures to be predictable and at a level that does not disadvantage economic growth in both domestic and international competition. The system should work within the parameters of accepted cultural norms of equity and fairness so it does not foment unnecessary voter dissatisfaction. All levels of government want to keep costs down to avoid crowding out other programs or increasing taxpayer discontent. Federal, state, and local governments are also concerned about their longer-term liabilities for the viability of Medicare trust funds, Medicaid costs, and their accrued liabilities for government retiree health benefits.
The federal government purchases health care on behalf of special populations: the poor, older adults, veterans, active duty military, Native Americans, and so forth. It pays for more than 40% of health care purchases (and covers more than 60% of patients in some markets). Children have actually fared better in federally purchased health care since 2000 because of the 1997 startup of the State Children’s Health Insurance Program (SCHIP). Federal programs, which are highly sensitive to political pressures, have tended to rely on their purchasing power to garner deep discounts. (Only recently have governments begun to encourage evidence-based medicine and to refuse to pay for avoidable costs such as hospital-acquired infections.) Because of the low federal reimbursement rates, some providers refuse to participate in federal and state programs, further reducing access and availability.
State and Local Governments
The interests of state and local governments are much more limited, involving Medicaid and local programs for the uninsured poor. Their revenue streams are limited and inflexible, often being tied to real property taxes that cannot adapt rapidly to changing economic conditions. However, revenue restraints have encouraged innovation. State and local governments cannot print money to cover deficit spending. Despite all of the rhetoric at the national level, most experimental attempts to control health costs have occurred at the state level. For several years, states such as Maine, Vermont, and Massachusetts have been experimenting with systems to provide universal coverage using a variety of funding sources.
Prior to passage of the ACA, the governors of more than half the states had proposed measures that included one or more of the following approaches:
• Mandated insurance coverage for all citizens
• Mandated employer coverage or payments into insurance pools in lieu of coverage
• Mandated lower premium individual policies from insurers
• State coverage for all uninsured children
• Tax credits and deductions for individual insurance premiums
• Special discounts for prevention and health lifestyles
• Calling for expansion of Medicare to cover the uninsured (Barry & Basher, 2007; Solomon & Wessel, 2007)
Although the ACA institutionalized some of these once-experimental approaches at the national level, state-by-state experimentation is expected to continue.
Governments are also concerned about appropriate access for all of their constituents. The case at the end of this chapter provides the example of the U.S. Department of Health and Human Services standard for Culturally and Linguistically Appropriate Services (CLAS). Some parts of this standard were once mandatory for services paid for with federal funds; since 2013, they are all guidelines. The states developed, and the ACA now supports, simpler portals of entry that allow low-income families to submit one application to determine their eligibility for multiple programs.
What Does the General Public Want?
Members of the general public want to feel that they and their families are safe and that the system will treat them fairly and effectively if and when they need it. This requires access to health care, which means health insurance coverage. They also do not want to feel guilty about the plight of their uninsured fellow citizens. At the same time, they are not enthusiastic about using the tax system to cover the needs of others. They do not want to be treated in a way that marks them as a member of any underclass, but want to be treated as middle class or above.
Americans seem unwilling to pay more than the current proportion of national income (about 19%) for health care, yet the inflation rate in health care continues to exceed the rate of growth in our overall economy (growth in gross domestic product [GDP]). International economic comparisons have shown a close relationship between national income and per capita health expenditures, but with the United States as an outlier. Wealthy nations do spend more per person. This would seem to indicate that part of the cost of health care is related to need, part is related to availability, and part is related to decisions people make as consumers.
Individual Insurance Purchasers
The problems affecting small businesses are even worse for the self-employed seeking coverage. Premiums are highest and rejections frequent. Many end up going without coverage. Yet the self-employed often have an advantage over the working poor who are unable to obtain insurance through their employer—because it is not offered, because they only work part time and are not eligible, or because they cannot afford the added expense.
The exchanges and the premium subsidies for low-income families under the ACA will help with those concerns. It remains to be seen whether the premiums for approved coverage at the minimum cost are financially feasible for those in need.
What Do Policy Wonks Want?
The policy wonks want a system that is efficient, coherent, and rational and that provides effective care to the relevant populace. Health care competes with other services for scarce resources. Money spent on health care cannot be spent on transportation or public amenities; therefore, there must be some calculus for allocating scarce resources to health care and other meritorious causes on a consistent basis. Analysts are sharply divided on many other issues. For example, although many argue for measures to forestall continued growth in health care expenditures, others say, “Don’t worry—the U.S. citizenry can afford it and it constitutes economic growth and increasing employment even if it were to approach 25% of our economy.” Others say, “Yes, that is growth, but it represents a transfer of assets from the young to the elderly that is not sustainable.”
Much care is effective and worth doing, but there is agreement that there is considerable waste and inefficiency, even though waste and inefficiency are income-enhancing for someone. Examples of other areas of concern to policy analysts include the following:
• Free riders. As discussed earlier, individuals who could otherwise pay but avoid doing so while still relying on the system for help in case of a catastrophic event are a stress on the system. Some individuals will chose to pay the penalities under the ACA rather that purchase insurance.
• Overserved and underserved areas. Not only are health care resources limited by the willingness and ability of governments, firms, and individuals to pay, but available resources can be poorly distributed, resulting in surpluses in some areas and shortages in others. Governments and payers have attempted to regulate the supply of health services as well as the demand. One example of the regulation of supply is certificate of need legislation. In an attempt to regulate against an oversupply of health care capital investments, many states have legislation that requires independent review to determine whether additional investments are warranted. If not, the services they provide cannot be compensated for from state and federal funds. Examples of the types of capital investments reviewed include hospital beds, nursing home beds, cardiac catheterization units, and expensive imaging equipment. Legislation has also subsidized the building of hospitals and the posting of health professionals to serve needy populations.
• Withdrawal of services. Demand is constrained when payers restrict what they will pay for and how much they will pay for what is delivered. The absence of sufficient demand or reimbursement for services can lead professionals and provider institutions to withdraw from the market, downsize, or file for bankruptcy. Because of high malpractice insurance costs for obstetric procedures, for instance, many obstetricians have stopped doing deliveries and only provide gynecologic services. Many hospitals have reduced their psychiatric beds, shifting the burden to the state institutions. Some withdrawals are responses to overcapacity in an area, but others are the result of decisions that a particular line of services is bound to lose money.
Proposals to solve the access problems seldom mentioned much about the supply of services available or the impact of a large increase in volume on prices and costs. In the minds of many, universal coverage and costs seem to be separable issues. We learned that they cannot be separated when Medicare and Medicaid were introduced and medical expenditures rose rapidly.
There are specific things that a majority or a plurality among each set of actors want to see happening in the health care system. For the most part, there are clear majorities on the need for providing insurance for all, controlling the rate of inflation, eliminating waste, improving quality, investing in the most beneficial programs, taking care of children and the older population, and pushing ahead with research to find cures for diseases. Yet there will be a vocal minority on just about every issue—largely people representing special interests and those with strong economic and social ideologies. All of the areas of general agreement are reflected to one degree or another in provisions of the ACA, but these provisions represent compromise, incrementalism, and political pragmatism. There is extensive opposition, and we have much to learn about how theory translates into practice. That is why we believe in the continuing importance of policy analysis as a way toward maximum possible rationality in decision making, fewer ungrounded assertions, and increased ability to deal with new evidence and new opportunities.
Case 4: National Standards on Culturally…
Case 4 National Standards on Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS)
In 1997, the Office of Minority Health (OMH) in the U.S. Department of Health and Human Services began work on national standards for culturally and linguistically competent health care. The stated goal was to reduce health disparities. In December 2000, OMH released the standards. Although the standards were primarily directed at health care organizations, OMH encouraged their use by individual providers as well as by policy makers, accreditation and credentialing agencies, purchasers, patients, advocates, educators, and the health care community in general (OMH, 2001).
OMH began reviewing and revising the standards in fall 2010. The National CLAS Standards Enhancement Initiative included three lines of inquiry: a literature review, a public comment period, and consultation with an advisory committee. The purpose was to revise the standards “to reflect the past decade’s advancements, expand their scope, and improve their clarity to ensure understanding and implementation.” Precipitating factors, according to OMH, were increasing diversity in the U.S. population and rapid growth in the fields of cultural and linguistic competency.
This process culminated in the April 2013 release of a set of enhanced standards (OMH, 2013a). In the supporting documents, OMH explicitly defines health to include physical, mental, and social well-being. Cultures deserving of appropriate services include those identified by geographic, religious and spiritual, biological, and sociological characteristics, in addition to racial, ethnic, and linguistic groups addressed by the original standards. OMH also expands the target audiences and the target recipients—from “health care organizations” to “health and health care organizations” and from “patients and consumers” to “individuals and groups,” respectively (OMH, 2013b).
The original 14 standards included a mix of recommendations, mandates, and guidelines. The 15 enhanced standards are all guidelines of equal weight.
To encourage successful implementation of the enhanced standards, OMH published The Blueprint, an extensive implementation guide with explanations of each standard and listings of resources (OMH, 2013b). OMH declared that completion of the enhancement initiative means that for the next decade, the 2013 standard will “serve as the cornerstone for advancing health equity through culturally and linguistically appropriate services” (p. 155)
1. Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.
GOVERNANCE, LEADERSHIP, AND WORKFORCE
2. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources.
3. Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area.
4. Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.
COMMUNICATION AND LANGUAGE ASSISTANCE
5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.
6. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.
7. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.
8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.
ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY
9. Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations.
10. Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into measurement and continuous quality improvement activities.
11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.
12. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.
13. Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.
14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints.
15. Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public (OMH, 2013).
Source: Reproduced from: Office of Minority Affairs, Department of Health and Human Service. (2013). National standards for culturally and linguistically appropriate services (CLAS) in health and health care. Washington, DC: U.S. Department of Health and Human Services. https://www.thinkculturalhealth.hhs.gov/pdfs/enhancednationalclasstandards.pdf. Last updated 3/3/2013. Accessed 11/5/2013.
1. OMH has said the enhancement initiative followed a decade of successful implementation of the 2000 standards, but the news media have reported on implementation problems, and the 2013 standards were released with an implementation manual almost 200 pages long. What do you think might be some barriers to implementation, and what would you suggest to encourage implementation?
2. What do the expanded definitions of health and culture say in general about the way government framed health in 2013 as compared to 2010? What might have contributed to the change?
3. How do you explain the differences between recommendations, guidelines, and mandates? What are the possible explanations for making all enhanced standards guidelines?
4. Which are the most important standards in your opinion? Which are the least important? Explain your reasoning.
5. What would you change about these standards if you were in charge of the U.S. Department of Health and Human Services?
6. Does it seem unusual to you for a government agency to wait more than 10 years to review and revise standards like these? What might be the reasons for waiting? What arguments could be made for more frequent review?