On Jan. 20, Barack Obama will become the 44th President of the United States against the backdrop of two foreign wars and one of the worst economic crisis since the Great Depression. U.S. business icons are failing; unemployment is at its highest rate in decades; housing values are plummeting as foreclosures and credit tightening make the American dream of home ownership more of a nightmare than a reality. Personal net worth is shrinking and the financial ability for some to even consider retirement is fading away.
Yet, at the same time there is dire need to structure and re-invent many institutions. Our infrastructure of roads, buildings, and bridges has been neglected and are in disrepair. Our education system is not preparing our young people for a global market, a place where the best and brightest may now be found in India, Japan, Europe, and China, as much as in the U.S.
And healthcare, my oh my healthcare, needs more than just a face lift; it needs an overhaul, a righting of the ship, and a truing up of its direction for the future.
Yet, fixing healthcare is very much intermingled with the rest of our economic woes. With company failures and layoffs comes the loss of health benefits, and, ironically, more time available to seek healthcare. Even those with jobs may find themselves with no insurance or inadequate coverage. It is not unlikely the current 47 million uninsured will soon be joined by another 15 million uninsured or underinsured, made up mostly of middle-class workers who have never before been faced with the prospect of financial ruin if they or their family members take ill. Never before has the middle class been faced with the choice between the right care they need and losing all of their net worth, including their homes.
President Obama could be another Jimmy Carter, an intelligent, well-meaning man whose presidency was disabled by 13% inflation, gas lines, and being held hostage in Iran. Or he will be the next FDR, a president who remade America for generations to come, with Social Security, work programs, and a new economy.
Fortunately, Obama’s team is loaded with thought leaders who come with a strong interest in reforming and rebuilding healthcare. Tom Daschle, the new secretary of Health and Human Services has a long history of healthcare policy and can work well to move things through a Democratic Congress. Obama’s Director of the Office of Management and Budget, Peter Orszag, is a well-regarded health policy expert. Melody Barnes, his domestic policy advisor, was the executive director of a think tank, the Center for American Progress, which has developed a detailed road map for change in our healthcare system, involving some of the best minds in American healthcare, such as Don Berwick, David Blumenthal and Paul Ginsburg. You can read the center’s 120-page report at http://www.americanprogress.org/issues/2008/10/health_care_delivery.html.
While this group appears primed for a revolution, rather than just rearranging the deck chairs on the Titanic, at this point Obama and his team have been more visionary than specific. Here is my best guess as to what some of the aspects of a new healthcare approach might be. (And most of these changes are of more than a passing interest to hospital medicine.)
There is no doubt it is unsustainable for a first-class society to have so many citizens without access and payment for healthcare. Although this may start with covering all children and offering people affordable insurance not specifically tied to their employment, the U.S. must move closer to something that looks like Medicare for all. Along the way, this will lead to more regulation of insurance companies to raise the percentage of the premium dollar that actually goes for medical care (75% is just not tolerable). Do not expect the $2.1 trillion healthcare pie to expand, so doctors and hospitals will need to be more efficient and effective as they supply better, more accountable healthcare to a larger patient population. Some may perceive this as more work for less pay.