On the Future of U.S. Health Care Financing

No matter how much we talk about global health issues like infectious disease, maternal health, and the role of education, at the heart of every problem we are facing is the question of financing health care initiatives. Perhaps the only other variable so crucial to population health is stewardship, and a large part of stewardship concerns judicious management of funding.

Two videos recommended for this week brought up provocative issues on the future of health care financing in the U.S.: Uwe Reinhardt's lecture and the California OneCare initiative. California OneCare lobbies for universal health insurance, calling for swift steps instead of small changes. The biggest issues we face are administrative costs and lack of access to care for a staggering chunk of the population. Also disturbing are inequities in the quality of care people receive, a measure closely linked to SES and race.

Many other countries use a single-payer system to control administrative costs. Canada and the UK are just two examples. Health care investigators in these countries would be quick to tell us that the single-payer system is no panacea...it has its own disadvantages, like everything else. However, at the heart of the current health care crisis is a civil rights issue that the single-payer system might address: unquestionable inequity in the ability to attain something that is, at least ideologically, universally considered to be a basic human right.

Even developing countries understand (and act on the understanding) that the way we do health care doesn't cover the most vulnerable people. In this country, over half of family bankruptcies filed are a direct result of medical expenses. 3/4 of these people have jobs. They are productive individuals of society crippled by a health care system that's supposed to increase their productivity. Instead, it's leeching it.

If that's not convincing enough, consider this: a 1% decline in income in the U.S. translates into an increase in mortality rate of 22 deaths per 1000. In Canada, no association is found between income inequality and mortality rates. Infant mortality rates show similar results, with the world superpower ranking in the 40's on the list of country-specific rates.

Fundamentally, health is more important than money. Anyone who's ever experienced a serious illness, even a bout of flu, can tell you that without your health, your money doesn't mean much.

Unfortunately, that piece of wisdom is no longer true, and it's least true in places like the U.S., where both health and money are available, but money is infinitely more important than health. Here, money buys health and happiness. What is wrong with this picture???

Back to that paradigm shift we talked about. Sure, we'll have to iron out some kinks in a single payer system to adapt to our needs as a country. But what we're doing right now--taking those kinks and calling them reasons not to act in the best interests of human beings--can't continue. We must first accept that inequality of some sort may always exist, and then go about decreasing it as surely as we can, as other nations--even less developed ones like Korea, Brazil, and India--have done.

And one more thing: an equality of opportunity, as the U.S. has historically been praised for having, is not the same thing as equality. There are several forces, some known and others unknown, working against equality. For instance, racism and SES interact additively to produce poorer health outcomes for certain groups of people. This holds true even when patient characteristics are held constant. What does this mean? It means that somewhere among health care providers and institutions, inequality is being perpetuated. It means that addressing individuals is not enough; the entire establishment must be examined. We must ask important questions: Are doctors giving every patient the same quality of care? Are there good hospitals in largely ethnic areas? Good schools? What are the differences? Our country likes to believe that racial segregation was so long ago that its effects are no longer profound. We have made great strides (remember, in the late 18th century an African-American slave was only roughly 3/5 of a human being). But vigorously addressing contemporary manifestations of these issues will greatly aid a successful reworking of health care financing in this country.

In order to treat some persons equally, we must treat them differently.
-Harry Blackmun

Internet Access and Health Outcomes

my Grandma:
one of the smartest people I know!

I recently went back to my hometown for a visit and realized that some of my dearest friends and family do not have access to the internet. This may seem obvious and acceptable, but to me it is neither.

Who are these people in my life who are so archaic they don't have internet access even though they can afford it? Well, 1) my grandma and 2) dear family friends who are not-so-recent migrants.

I was studying at my aunt's house the other day when I decided to see what my grandmother thinks of YouTube.com. (This post is supposed to be about health outcomes...we'll get there). I typed in 'Andhra Pradesh' (our home state in India) into the search bar, and six pages worth of videos came up. We watched a few videos on Indian freedom fighters during the time of Gandhi. My grandma was a little girl during India's freedom fight--she recalls witnessing her elder brother being beaten by British-hired Indian law enforcement officers for his revolutionary activities. The videos, which were even narrated in her native Telugu, brought back all sorts of memories for her. She even talked about writing a book about her brother's role in the fight for Indian independence. She was jazzed.

My aforementioned migrant friends could benefit from internet access too. Some of them don't speak English at all. They make enough money to afford a computer and the internet, so the barriers are not financial. They just don't have the freedom to do things like take time off from work to do something frivolous like educate themselves. But there is a crucial point to make here--just as we discussed in the first weeks of class, and just as UK & Netherlands authors Wagstaff and Van Doorslaer (gold standard researchers on poverty and health) point out, the effects (i.e. the cost) of not having things like the internet are much more significant for disadvantaged people. In other words, it would mean a great deal more to my grandma, or to my migrant friends, to have internet access, than it means for someone like me to have it.

What would it mean? The possibilities are endless. For my grandma, maybe it means delayed onset of dementia. Less depression, anxiety and social isolation (she can connect with others and entertain herself as she gets older and cannot move around as much). Fewer medical episodes. For migrants, it also means access to empowering information that may well give them the freedom to see education as a basic right/need rather than a peripheral idea. It would mean access to services that they would otherwise have no way of knowing exist. Faced with all this new technology, it seems that education is more important than ever. Increasing access and utilization are key.

I spent some time teaching my grandma how to use my aunt's PC. She's a quick and eager learner in her mid-80's. Her biggest challenges were learning how to operate the mouse and focusing her eyes on the screen. I wonder why the local senior citizen center offers arts and crafts, but not computer classes? There's so much human potential out there, sometimes in the most surprising places. From that perspective, the field of public health would do something incredible if it focused on ways to give people the tools they need to live productive lives. Because for many (if not most) people, feeling productive = feeling truly happy.

Biotech for Development: A promising solution or a pipe dream?

There is no easy answer to the debates over where pro-poor development funds should go. As part of the whole paradigm shift we keep referring to, I think every field has to redefine its priorities. Biotech was the topic last week, and one of the controversies surrounding pro-poor biotechnology is the question of whether the vast amount of funding required to develop a new diagnostic, a new vaccine or a new drug is really worth it. Rich countries can argue that drugs already developed are very poorly distributed. Why fuel new innovations that will only widen the gap?

While committees concern themselves with that, paradigm shifters in the field have showed some promising advances, including new vaccines and low-cost treatments that are showing promise in advanced-level trials (anti-malaria vaccine, paromomycin treatment for kala azar). In a
New York Times article posted by Dr. Shahi awhile ago, Tina Rosenberg points out that vaccines have only been around for 20 years. In 20 years, they've made an enormous difference in a child's ability to survive the first five years of life! Who would have thought that such a labor-intensive project, which requires hunting people down in all corners of the world one by one, could be so successful? Who could have predicted that wars would be halted for vaccination campaigns? And yet it happened, and it changed everything.

Another example: The human genome was discovered two years ahead of time, and well under budget. According to one account I recently read, these unexpected outcomes were largely attributed to competitive cooperation among investigators. Again, it would seem impossible to unravel something as complicated as the human genome ahead of schedule simply because someone wanted to beat everyone else to it. And to do it more cheaply than expected, to boot. But that also happened, and it changed everything.

But we seem to forget history. Or maybe we're unaware that we're the ones making it. It's ironic, but one of crucial ways of achieving a paradigm shift is, I think, examining history in an attempt to understand just how we got to where we are now. There's an astonishingly accurate (and somewhat grim) picture of human nature buried in there, and confronting it proactively may provide some rationale, motivation, and clues to shifting that paradigm.

To learn more about biotech's role in global health, check out this article on the ten most promising biotechnologies for human development.