Two Important Numbers in Health Reform are 5 & 50

5 & 50 are two numbers that explain where half of all healthcare expenditures go in America today and represent a key area health reform must address.

We often here about the $3.5 trillion we invest annually for Healthcare in the United States. Breaking this down further, this means we spend an average of  $10,739 per citizen.

This last number demonstrates how statistics can sometimes be misleading. As noted, we spend an average of $10,739 per citizen.  But, understanding where the money is actually going provides a key insight as to why our investments are high but results are often lower than other countries spending less.

Look closely at where the money goes you see that five percent of people account for 50 percent of total health spending.

Think about these stats for a moment.

Health-care spending represents almost one-fifth of the United States’ economy.

In digging further into these numbers, the data from the National Institute for Health Care Management suggests that the health problems of about 15 million Americans consume almost one-tenth of the Gross Domestic Product (GDP) of the United States — around $1.7 trillion.

Those citizens in the “five percent” group are known as “super users” of the health system.  They include the “sickest-of-the-sick” or have multiple chronic conditions requiring intense and continuous care regimens.

We are bombarded with stats that show, on average, the United States spends more on health per citizen than any other country on the planet. The reality is that most of these expenditures are concentrated on fewer people entering the health system once they are very ill (including being admitted to expensive, technology rich environments when nearing end-of-life).

Ethicists often ponder the issue of distributive justice…How do we use a finite amount of resources to do the most good for the most people?

To raise the question above is not to suggest we turn our backs on those women and men who are members of the medical “super-users” group whose lives (including quality of life) are dependent on utilizing the system in place today.  

If we are serious about true reform, the deeper issue to consider is how we change the systems super-users are dependent on to better serve their needs while becoming more effective stewards of the resources required to meet the needs of this vulnerable population.

As we look ahead, these questions are worth considering by anyone in, or touched by, the current healthcare system.


For Consideration:

  • What is your view on whether half of all resource expenditures should go towards supporting the needs of a small group of people?
  • The rapid growth of the elderly population (a baby-boomer now turns 65 every 15 seconds and will for the next decade) will expand the size of the “super-user” group requiring intensive & costly services. What alternative or innovative ideas would support the needs of this population while making better use of our resources?
  • Do you know someone who is a “super user” of the health system? What services are they dependent on? What might you change to better serve his or her needs while make better use of resources?

Resources:

If you want to go deeper in exploring this topic:

There is a great article in the Atlantic by writers Karen Weintraub and Rachel Zimmerman. Fixing the 5 Percent is a thoughtfully-written piece that explores both the problem as well as solutions others are pioneering to improve the effectiveness of services and costs.

If you want to delve deeper in the actual data and trends download this PDF from the Agengy for Healthcare Quality and Research


References:

National Health Expenditures by type of service and source of funds, CY 1960-2015. CMS.   https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/NHE2015.zi

“UNDERSTANDING U.S. HEALTH CARE SPENDING”. National Institute of Healthcare Management, July, 2011. http://www.bcnys.org/inside/health/2011/HealthCarePremiumsNIHCM0711.pdf

“The High Concentration of U.S. Health Care Expenditures”. Agency for Healthcare Research and Quality. https://archive.ahrq.gov/research/findings/factsheets/costs/expriach/

http://www.washingtonpost.com/blogs/wonkblog/wp/2013/09/19/the-two-most-important-numbers-in-american-health-care

The Single Most Important Question in the Reform Debate

Regardless of your political leanings your approach to any reform proposal will be anchored to this single question.

Regardless of your political views or social priorities, your approach to any health reform proposal or debate should be anchored to a single question. Directly or indirectly, how you answer this question is central to evaluating any proposal for creating sustainable reform.

The question that is foundational to all others in the health reform debate comes down to this:

Is healthcare a right or a privilege?

For the record, while most other developed countries have constitutionally declared or legislated healthcare as a right for all citizens, America has not. This is not an editorial comment but a statement of fact.

When the framers of the Constitution and Bill of Rights were defining fundamental human rights, average life expectancy was 35 years of age. [i]  The concept of “healthcare” as we know it today simply did not exist.

Healthcare as a right means that all citizens are guaranteed access to some level of care or services. While the type or level of service might change, the commitment of equal access to “something” does not.

For example, Canada decreed healthcare as a right in 1984.  Their system is known for guaranteeing all citizens access to certain services but often then keep patients waiting in line to access services based on budgetary targets. The United Kingdom guarantees all citizens the right to care with a founding principle of “free at the point of service” but often have some people waiting in line for service while others buy supplemental insurance policies that allow them to “jump the que” and gain better access to services.

Regardless of how the system is organized, or how well it actually works, healthcare as a right means that there is a safety net that catches all citizens.

The debate about healthcare as a right in America began with the advent of two events in history.

The first was the beginning of the Industrial Revolution. A massive shift of people going from working on farms to factories gave rise to a new set of health issues and began the debate on the role of private companies and the government in providing for the health of workers and citizens.

Around the same time medicine moved out of the shadows of quackery and into the realm of being a repeatable, scientific discipline.

Ever since, America has wrestled with whether healthcare is a right or privilege.

In the 1940’s President Roosevelt attempted to address the issue of whether healthcare is a right as part of a broader social initiative known as America’s “Second Bill of Rights.”

As WWII was coming to a close, FDR put forward a sweeping social program known as America’s Second Bill of Rights that included healthcare.

In 1945 President Truman proposed a national health program to include all Americans declaring in a speech to Congress “We should resolve now that the health of this Nation is a national concern; that financial barriers in the way of attaining health shall be removed; that the health of all its citizens deserves the help of all the Nation.”  It was denounced by the American Medical Association and called a communist plot by a House subcommittee.[ii]

The Clinton administration made healthcare their top platform priority but failed to get a plan through Congress.

Finally, the Affordable Care Act was passed during the Obama administration (aka Obamacare) in 2010 that created vehicles for citizens to have access to health plans while mandating coverage and fines for those choosing not to participate. The Trump administration from the outset worked to disassemble the Affordable Care Act.

The brief history of Affordable Care Act noted above is a cautionary tale that shows us that until healthcare is deemed a right, the fate of lasting reform will rise and fall based on the whims and views of those who control Congress and the White House (This situation continues to play out as I write this article).

An interesting corollary to the right to healthcare is our view and laws pertaining to the “right” to education. While the U.S. Constitution does not explicitly enumerate a positive fundamental right to education, a series of court decisions and legislation provide any citizen a right to a certain level of education.

As daunting as it may seem, American voters, business and political leaders have shown that they can commit to healthcare as a right in certain circumstances.

Healthcare has been decreed as a right in certain situations and for certain people. As part of the Great Society, congress enacted legislation in 1965 to guarantee seniors the right to healthcare via the Medicare program and to assist states in the provision of health services to the indigent via Medcaid.

And, since 1986, all citizens have a right to assistance in an emergency room…Unfortunately, the law only requires that a patient be stabilized. [iii]  After that you are subject to the whims of the situation.

If you believe that healthcare is a right, then any proposal for reform must call out and explicitly address this issue.


For Consideration:

  • Do you believe healthcare to be a right or a privilege?
  • If you believe healthcare to be a right, the question that follows is “a right to what?”  Is there a set of services to which everyone has access?
  • How should any proposal for reform address these fundamental questions?

Additional Resources

To better understand the history of this issue in the United States, see the article , Health Reform – What a Long Strange Trip It’s Been.

Learn which countries have Universal Health Access and explore how each has achieved this status (single payer, private system mandates, other models) from Wikipedia.

References:

[i] http://keywen.com/en/LIFE_EXPECTANCY

[ii] Dr. Howard Markel, “69 years ago, a president pitches his idea for national health care”. November 19, 2014. PBS Newshour. http://www.pbs.org/newshour/updates/november-19-1945-harry-truman-calls-national-health-insurance-program/

[iii] Health Care for Some: Rights and Rationing in the United States since 1930. Beatrix Hoffman.  University of Chicago Press. 2012

Health Reform Heroes: What can we learn from Rwanda?

Only twenty percent of citizens have electricity, but everyone has universal access to this life-changing service.

Other countries have proven that health, government and business leaders can work together to decide on what all citizens should have access to and create programs to provide universal access even in the most challenging of circumstances.

Such is the case in Rwanda. Five years ago, the government made a commitment to create a nationwide program to provide universal eye care to all citizens.

Why vision care? More than 2.5 billion people around the world suffer from poor vision without access to even the most basic treatment. Poor vision affects the ability of a child to see a classroom chalkboard or learn to read. It affects an adult’s ability to work.  

Making a singular commitment of providing universal access to vision care for all citizens was just right for a country like Rwanda. This choice addressed a health issue affecting all citizens, did not require an expensive, high tech solution and contributed to health improvement in ways that help break the cycle of poverty, especially for women.

To make universal access to eye care possible, a public-private partnership with Vision for a Nation was created to train nurses, build supply chains for glasses and eye medications, and visit all 15,000 of the country’s villages.

As of last year, the government took over responsibility for the management and financing of the services. To date, more than 2.4 million eye screenings have been carried out with over 1.2 million treatments provided.

And so, what does the good work in Rwanda have to do with health reform in the United States? Let us recognize that the United States and Rwanda are worlds apart geographically, economically and socially. But let us also not lose sight of the fact that in a poor country where less than 20 percent of the population have access to electricity, all citizens have access to a health service that improves health and allows them to lead better lives. This life-changing service is available to all because the leaders of Rwanda made it a priority and built a coalition of like-minded people and organizations to make it a reality.

As we look ahead to the process of defining, debating and developing new approaches to the health delivery system in America, imagine if elected leaders would start by “crossing the aisle” to select one thing to which all citizens would have access. This focus would provide the dual benefit of measurably improving outcomes while empowering citizens to lead more healthy productive lives. At the same time it would demonstrate that those we’ve sent to Washington D.C. could actually work together to accomplish something meaningful.


For Consideration:

  • If the United States could demonstrate change by providing its citizens universal access to one service or area, what would it be (and why)?
  • Do you believe all citizens should have equal access to a set of services? If yes, broadly what should be covered?
  • Consider asking your elected officials what one thing would they be most willing to champion to improve access to health services that benefit everyone.

Additional Resources:

Learn more about the work of Vision for a Nation and its mission to unlock the potential of the world’s poorest communities by making eye care globally accessible.