A trio from the NEJM on health reform:
- Nicole Lurie (Assistant Secretary For Preparedness Response) on H1N1 Influenza, Public Health Preparedness, and Health Care Reform:
In the event of a large-scale health emergency such as an influenza pandemic, the health care system will experience unprecedented demand. Although much care can be provided outside hospital settings, intensive-care resources will be in particularly short supply. Determining how to retain — and pay for — the capacity to "surge" in such an event is a critical aspect of health preparedness; it is particularly challenging, however, because one way to achieve the cost-containment goal of health care reform is to shift care from expensive inpatient settings to less expensive outpatient settings. New approaches, including self-triage guidelines, remote monitoring devices, and telemedicine, support such shifts in the delivery of care. Research suggests that building excess emergency-department and inpatient capacity as a sort of insurance policy may not be a sound approach and will only increase health care expenditures: if capacity is there, it will be used for other, nonemergency care. Unfortunately, we have not yet found the right payment policies to ensure that hospitals will be able to defer elective procedures and discharge patients who are less severely ill in order to make space for those who are more acutely ill.
- John K. Iglehart on Setbacks and Fissions — Reconsidering the Scope and Timing of Reform:
Democrats find themselves suddenly facing a much steeper climb toward reform. Their arguments that the health care system is on an unsustainable spending path and that now is the time to act are being overshadowed by growing discomfort among some voters that government has already overextended its reach and by charges that the elderly will be put at a disadvantage. Many of the arguments (that reform would create "death panels" and lead to the rationing of health care on the basis of age, for instance) are unfounded, but they are helping to fuel the discontent. Although many Democrats would view a less expansive reform bill as tantamount to defeat, such an approach would reflect the long-standing pattern of U.S. policymaking on health care, which has favored incremental steps rather than comprehensive leaps.
- Robert A Levine, MD on Fiscal Responsibility and Health Care Reform:
To reduce administrative costs and simplify the system, I believe that a single-payer system that provides universal coverage is mandatory. Of course, this concept is anathema to free-marketeers and does not currently have much public resonance — largely because Americans have been misled by negative advertising and denigration of the single-payer approach by politicians and others who label it "socialized medicine" and government interference in medical care. A new advertising campaign using the Internet as well as traditional media might help to educate the public about the benefits of this approach. A single-payer system could be run by a federal board that would be independent of the government, appointed by the president, and confirmed by the Senate. The board would function in a manner similar to that of the Federal Reserve, with the assistance of committees of experts and immunity to political interference. Regional health care entities operating under the board’s aegis could be used for the day-to-day management of health care delivery.
In other news: