With fewer than 100 days until the first primaries, the leading candidates have received ample airtime to address the important issues our nation faces. But even though health care accounts for around 18 percent of our nation’s GDP and consumes close to half of the total tax revenue collected by the federal government, their silence on providing solutions to the most pressing health care challenges our nation faces continues with few exceptions.
Politico concluded the latest Republican debate contained “very little on Obamacare, virtually nothing on Medicare and Medicaid and no mention of drug prices.” And the same sentiments were expressed by others following the most recent Democratic debate.
Perhaps that’s understandable at this point in the election cycle. As New York Governor Mario Cuomo memorably remarked, candidates campaign in poetry and govern in prose. And the heath care policy choices we have to make are by nature far more prose than poetry.
What little discussion about health care has taken place has come along standard, predictable party lines whose messages we’ve heard for a long time. Republicans have consistently called for a strategy to “repeal and replace” the ACA and de-fund Planned Parenthood, while the Democrats have urged us to preserve and protect traditional Medicare and expand Medicaid.
The next President will need to address a variety of issues that threaten the physical and economic health of our country. As such, voters are entitled to hear each candidate articulate a clear point of view on the health care issues that affects not only each of us every day, but also our country as a whole.
To stimulate debate, I’ve come up with five questions for the candidates and provided a summary of the historical context and potential outlook for each. The five questions deal with issues that remain front and center — rising health care costs, the shortage of primary-care physicians, payment gaps in Medicare and Medicaid, soaring drug prices, and regulating health care IT.
1. The rising cost of health care spending — “Should the Federal government act to restrain it, and if so, how would your Administration work with Congress to slow it down?”
Context: Health care costs have grown significantly faster than GDP for decades. At the current rate of increase, health care costs as a percentage of GDP are projected to double over the next 20 years. That would result in our nation dedicating more than one-third of its entire economy to health care services.
Outlook: All of the candidates recognize this as a problem. They know the sustained rate of increase beyond GDP growth has led to stagnant wages for workers and ever-increasing out-of-pocket expenses for patients. But the candidates also understand that proposing substantive changes will upset those who benefit most from the payments and incentives in the current system. This poses major political challenges as the candidates court the constituencies needed to win the nomination and the general election.
What each candidate recognizes is that constraining health care spending will limit job growth in this sector of the economy. Overall, about two-thirds of total health care expenditure is on people, including doctors, nurses, technicians and aides. And the impact of reduced costs on employment is not minor. If health care over the past 20 years had gone up at the rate of overall GDP, health care today would account for only about 10 percent of GDP, closer to that of the 34 other countries in the Organization for Economic Co-operation and Development. But the hundreds of billions of dollars in reduced spending would have meant that five million fewer jobs would have been created in health care over that time.
Depending on one’s perspective and what the nation did with those dollars, some would view this outcome as positive, but others would see a significant problem. On one hand, the lower spending over those 20 years would have led to fewer health care jobs, some of the best jobs in the economy. But on the other hand, it would have freed up resources for investment in other areas of the economy, with potentially even more opportunities for job creation. Every solution will be resisted by one party or another including some businesses, labor unions and a variety of health care organizations. All will continue to have a stake in maintaining the status quo, and each will be prepared to challenge the next President if he or she pulls hard on the reins.
In short, health care continues to be a major source of job creation in the U.S, slowing the growth of health care spending without impacting unemployment could be difficult.
2. Primary care — ” Do you believe the Federal Government should have a role in addressing the shortage of primary care physicians in this country — and if so, what approaches would you recommend?”
Context: The United States is running short on primary care physicians, according to the U.S. Department of Health and Human Services, by 2020 there will be roughly a deficit of 20,400 primary care physicians In the United States. The reasons are multiple, but the burden of college debt plays a significant role. Students complete college and medical school owing an average of $150,000 to $250,000. Medical students are attracted to specialty training that will bring incomes three to five times greater than if they become internists, family physicians, and pediatricians.
At the same time, primary care is essential to optimal health. Most interventions that improve health, help to avoid life-threatening problems, and extend life come from high-quality, accessible primary care services. Yet we continue to spend most of the health care dollar in the U.S. on specialty care. The result is that, as a nation, we lag behind other countries in quality outcomes in many spheres of health, while leading the world in the number of specialists currently in training and practice.
Research from the Dartmouth Atlas has demonstrated a correlation between higher concentrations of specialists in a community and increased cost of care. And the study also showed that the additional care delivered by these specialists did not increase quality — and, in fact, may actually have reduced it. And the problem is not just their higher incomes specialists earn compared to those in primary care. It also reflects the downstream costs of what they do, including frequent overuse of unnecessary diagnostic and therapeutic interventions.
Outlook: A first step could be to shift taxpayer-supported federal funding of residency programs from specialty to primary care. But the barriers to change here are significant. Individual hospitals with training programs do better financially when using these federal funds to create residencies in cardiology or orthopedics rather than in family medicine. And without narrowing the gap between primary care and specialist incomes, some of these new positions might go unfilled. But changing the current system of reimbursement will surely be opposed by a variety of national specialty organizations.
One option, would be for the government to write off medical school debt for new graduates who go into primary care. This “fix” – relatively inexpensive fiscally – might encourage more new physicians to pursue primary care rather than seek the highest paying specialty in the context of their medical school debts.
3. Medicare and Medicaid — ” How would you modify the government-sponsored health care services — federal and state — to address the gap between dollars being paid today and the true cost of the services provided?”
Context: Today, more than 35 percent of Americans are enrolled in a federal or state-sponsored plan. The government sets physician and hospital reimbursement rates in these programs. But as federal and state governments reduce expenditures to balance their budgets, the gap between what they pay and the actual cost of delivering care to beneficiaries is growing in most geographies. As a result, doctors and hospitals are forced to “cost-shift” to private insurers the added expense to make up the difference.
Outlook: Any time an entity can unilaterally set the prices it will pay, it impacts other participants in the market. Today, most private insurance companies are required to pay hospitals and physicians more to care for their enrollees than what the federal and state governments pay for the care their beneficiaries receive through these public programs. Adjusting what Medicare and Medicaid pay to be much closer to the true costs of the care provided will involve both political and economic calculations. And regardless of the conclusions reached there will be significant implications for purchasers, hospitals, physicians, patients and insurance companies.
4. Big pharma — “How can the U.S. strike a better balance between a fair and appropriate ROI for pharmaceutical manufacturers and affordable access to necessary medications for U.S. taxpayers and consumers – and what should Congress and the Administration do to address this?”
Context. There is a growing consensus that we need to put an end to excessively high drug prices. The cost of drugs in this country is among the top concerns of U.S. voters. Increasingly manufacturers are exploiting decades of legislative and regulatory protection, including long periods of patent protection, excessive grants of exclusivity beyond patent life, restrictions on re-importation, and the prohibition of the Federal government from negotiating prices with manufacturers.
Drugs account for a growing percentage of total health care spending today, and will rise rapidly in the future. The cost of brand and generic drugs are increasing on average by 10 to 15 percent annually, and specialty drugs are going up between 15 and 21 percent per year.
In most countries, the government negotiates drug and device prices with manufacturers on behalf of their citizens to balance an appropriate return on R&D for the manufacturers with the value of the products clinically and economically. The result is that people in most countries of the world pay less for particular medications than U.S. citizens do. As a result, the global pharmaceutical industry relies on the U.S. market to earn most of its very robust profit margin.
Outlook: The problem has grown much more visible over the past 12 months as a result of several highly publicized examples of greed. The stock markets have taken notice and penalized some of the companies, fearing government intervention. But those cases are just extreme examples of business buccaneers taking advantage of a broken system that is inflating the cost of drug therapy across the board. A clear, rational framework for the future that balances the needs of all will be essential. Hopefully the current Congress will begin the process, and give the next President the momentum he or she will need.
5. Health IT regulation — “How would you modernize the antiquated legislative and regulatory framework governing health information technology?”
Context: Much of the current legislation and regulations involving health IT were written decades ago, long before anyone envisioned the use of cell phones, video, and the Internet as important modes of care delivery. As a result, those restrictions have prevented the full exploitation of these technologies and failed to keep up with the pace of innovation. We will not be able to raise quality and lower costs in the future relying on the tools and technology of the past.
In a recent survey by Nielsen, funded by the Council of Accountable Physician Practices (CAPP), researchers found that fewer than 10 percent of Americans have access to the basic IT functionality that consumers demand from retailers, banks and airlines such as on-line appointment making and access to personal information 24 x 7. Even more problematic, few patients were aware of what was possible in health care, and the overwhelming majority of physicians had little or no interest in making those tools available.
The obstacles physicians worry about are many. The challenges to being reimbursed for the services they provide. Fears about security and privacy. Complex rules on how and to whom these services can be provided. How care must be documented and whether they can be credited by regulatory organizations when they address quality issues virtually, rather than in person. And the substantial variation in regulation that exists among the states.
Outlook: The ubiquitous availability of smartphones, mobile devices and video offers the potential to achieve health care’s triple aim — better care for individual patients, increased health of the community and lower annual cost per person. In this connection, telehealth should figure prominently in fulfilling the promise of technology. Modernizing Federal and State regulations to facilitate expanded use of these 21st-century technologies will be an important first step.
What our next president will have to do
These questions are complicated and politically charged, with no easy answers. But the next president of the United States will have to address these issues and find solutions. That means all the candidates now parading themselves before us will have to identify the areas they will tackle and offer their thoughts on whether they believe these changes should come through legislation, regulation, the White House or some combination thereof.
This much is clear: If we want to improve the physical and economic health of our nation, we won’t be able to do so without addressing the health care challenges our nation faces.
To our candidates, then, I say, “Speak up. We’re all ears.”
Robert Pearl is a physician and CEO, Permanente Medical Groups. This article originally appeared in Forbes.