Health Care Reform

Kaiser Permanente, The Permanente Medical Group, The Permanente Federation


Review by Morris F. Collen, MD
Spring 2010 - Volume 14 Number 1

Kaiser Permanente, The Permanente Medical Group, The Permanente FederationReaders of these two books will find them to be very informative and very timely during the current, contentious, national discussion on how to treat some major problems with the delivery of medical care in this country. Both books have been written by well-respected, experienced, national, health care leaders. Although both of these books are relatively easy to read, and are small-sized publications with about 150 pages, they will require thoughtful study to fully appreciate the extremely complex medical, social, political, and economic issues involved in trying to achieve President Obama's goal, which both authors strongly support, of having an affordable, high-quality, health care delivery system that will provide an acceptable level of patient satisfaction to every individual in the very diversified population of this nation.

In the Preface of Howard Dean's Prescription for Real Health Care Reform, Howard Dean, MD, describes his early experience of working on Wall Street; then graduating from Yale with a degree in political science; and later graduating from medical school at the University of Vermont with an MD degree. He writes that in 1980, while still practicing medicine, he was persuaded to go into politics. He was an elected member of the Vermont House of Representatives from 1982 to 1986. He was elected and served from 1987 to 1991 as the Lieutenant Governor; and from 1991 to 2003 as the Governor of the state of Vermont, where he instituted several reforms in health care programs. Dr Dean's unusual broad experience is the basis for his recommendations on health care reform.

George Halvorson has been a leader in health care delivery systems for more than 30 years. He was President and Chief Executive Officer of HealthPartners, headquartered in Minneapolis, before he became the current President and Chief Executive Officer of the Kaiser Foundation Health Plan and Hospitals, headquartered in Oakland, CA. He has served on several national health care committees; he has received prestigious awards for his leadership and achievements in advancing health care quality; and he has served as an advisor to several foreign governments on matters of health policy and financing. On the basis of his long and successful career in managing health care delivery systems, his fourth book describes his experiences and his recommendations for health care reform.

Mr Halvorson, in his Introduction, summarizes his harsh assessment that "Health care in America is badly organized, highly inconsistent, internally dysfunctional, sometimes brilliant, almost always compassionate, close to [being] data free, amazingly unaccountable in key areas, too often wasteful, too often dangerous, and extremely expensive."1pxv He writes that to address these problems, "We need clear goals, a strategy to achieve each goal, and the tools necessary to achieve each strategy."1pxv,xvi "We need to fix care and we need to enhance health."1pxvi In the ten chapters of his book, he presents what he calls, "… basically a kind of user's guide … useful in helping inform the current debate about how to save $2500 in the delivery of care and make care better in the process."1pxxiii He provides data indicating that improving care for a few key, common, chronic conditions, and avoiding "avoidable [care] mistakes"1pxxi could save "half a trillion dollars … and would have reduced the total cost of care in America by roughly 25%."1pxx He calls for a "national commission on health care costs and quality" and admits "It will take quite a bit of political courage … [and some] targeted re-engineering of both care delivery and care financing"1pxxiii to get this job done."

Dr Dean, in his Introduction, vividly describes some of the problems he encountered during his former medical practice when some of his patients were unable to obtain suitable health insurance because they had a chronic disease, or because it was determined that they had a pre-existing disease, or for some other reason. He writes, "More than 14 million Americans receive their health coverage on the individual market, but although these patients pay hefty premiums, only a fraction of the dollars are spent on providing actual care."2pxviii "Much has been made of the 47 million Americans who don't have medical insurance. But the healthcare reform debate should also focus on the fact that an estimated 25 million working-aged Americans have health insurance but still can't afford to see a doctor. … But our real challenge is dealing with the extraordinary damage that the private health insurance system has done to countless Americans who thought they had health insurance, faithfully paying huge amounts of money into the system over many years, only to find that their insurance company refused to stand behind them when they needed it most. … The real issue [is] …whether we should continue with an extraordinarily inefficient system that today features a private insurance industry that takes large amounts of money out of the healthcare system for shareholders, administrators, and executives while denying people the basic coverage that they think they have paid for."2pxix Dr Dean asks, "Should we give Americans under the age of sixty-five the same choice we give Americans over sixty-five? Should we give all Americans a choice of opting out of the private health insurance system and benefiting from a public health insurance plan?"2pxix In the first half of his book, Dean presents his analysis of some of the problems with current health care in America. He then describes in some detail the British health care program, and briefly reviews health care programs in some other countries. In the final section of his book he offers his recommendations.

Both authors agree with President Obama that everyone should have health insurance; and that the best way to eliminate cost-shifting, gross disparities between insurances practices, inefficient medical care and unnecessary procedures is to have a system that includes everyone. Mr Halvorson explicates the cost issue: "President Obama has called for us to reduce premium costs needed to insure an average American family by $2500 per family [or by about 21%] …. Universal coverage is a first step … covering everyone in the country can significantly reduce the price of insurance premiums … [since] part of the money now charged to people in their private coverage insurance premiums really goes to offset the cost of providing unpaid care to uninsured people … That shifted amount now adds roughly $1200 to the premium costs of each family contract … eliminating that cost shift … solves roughly half the target [set by Obama] …. To achieve the other $1300 in savings needed for family coverage, we will need to spend less money on care delivery … Do we have to ration care or deny services or care in some way to achieve these savings? No. We need to reduce the costs of care by improving care."2pxvii-xix

Dr Dean agrees that universal health insurance is essential, and advocates eliminating the "so-called free-loaders,"2p28 those who do not buy health insurance, "either because they can't afford it or because they choose not to."2p28 On the basis of his experience in Vermont, he writes, "I suggest that rather than mandating coverage, we supply health insurance essentially for free to everybody under thirty years of age, while also ensuring that everybody else can afford to purchase adequate insurance … People over thirty will buy health insurance if they can afford it."2p29,30 He also writes that "… the most important aspect of health care reform: Individual choice must not be merely preserved; it has to be expanded. … The federal insurance pool will include not just a number of private health care plans that … the individual … can choose from, but also has a so-called public entity… like Medicare … a government-run health care plan … [or a Medicare-like public option plan] … Without this option, I believe that health care will not be reformed."2p36,37 He also notes that, "… the for-profit health insurance companies have to supply a return on investment, large executive salaries, and advertising and administrative costs, all more expensive than in the public service." He concludes, "Without a public health care plan, health reform is simply unsustainable."2p47

Dr Dean emphasizes that, "Portability is essential for fairness in our system … If you leave your job for a better one or one in a different state, an insurer shouldn't be able to deny you coverage because you are too old or suffer from a preexisting medical condition."2pxx He also proposed, connecting the president's solution to global warming with revenues for healthcare paying for healthcare reform by …creating a new, sustainable, revenue stream by reducing the output of carbon dioxide …and imposing a tax on carbon emissions plus a 10% tax on gasoline.2

Both authors agree on the importance of the electronic patient record for improving the quality of medical care by making the patient's medical record universally available to all physicians who are taking care of a patient at the time of providing the care. Mr Halvorson urges that physicians have electronic access to "all of the information about all of their patients, all of the time."1pxxii Dr Dean writes from the physician's viewpoint, "… improved care will be a consequence of a system that has reduced duplication by means of a reasonable and universal technology for electronic medical records, hopefully put together by people who know as much about doctors and health care providers as they do about technology and software."2p28

Both authors emphasize preventive care, and cite data that indicates too few Americans receive all the preventive services recommended. Both authors recommend better management of chronic diseases that generate increasing costs especially for care of the elderly. Dr Dean also advocates expanding health research from its current focus on … "whether a particular medicine or treatment is safe and works"; to making "A greater federal investment in clinical effectiveness and cost effectiveness that compares different treatments and technologies."2p34 He also recommends having universal health care formularies (lists of expensive drugs) that physicians can prescribe. He advocates that all health plans use Medicare's policy of not paying medical care providers for "never events" when a patient suffers from a knowable and catastrophic mistake.

Howard Dean writes his book primarily from the viewpoint of a medical practitioner. George Halvorson writes primarily from the viewpoint of a health care administrator. Their books complement each other, and reading both will provide to the reader a more comprehensive review of the very complex problems facing this nation in its attempt to develop an affordable and high-quality health care program that is accessible to every American.

1. Halvorson G. Health care will not reform itself. Boca Raton, FL: CRC Press; 2009.
2. Dean H, Volsky I, Shakir F. Howard Dean's prescription for real healthcare reform. White River Junction (VT): Chelsea Green Publishing Co, 2009.


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