Understanding Health Policy: A Clinical Approach is a book about health policy as well as about individual patients and caregivers and how they interact with each other and with the overall health system. We, the authors, are practicing primary care physicians—one in a public hospital and clinic and the other, for many years, in a private practice. We are also analysts of our nation’s health care system. In one sense, these two sides of our lives seem quite separate. When treating a patient’s illness, it seems that health expenditures as a percentage of gross domestic product or variations in surgical rates between one city and another seem remote if not irrelevant—but they are neither remote nor irrelevant. Health policy affects the patients we see on a daily basis. Managed care referral patterns determine to which specialist we can send a patient, the coverage gaps for outpatient medications in the Medicare benefit package affects how we prescribe medications for our elderly patients, and differences in access to care between families on Medicaid and those with private coverage influences which patients ended up seeing one of us (in the private sector) and which the other (in a public setting). In Understanding Health Policy, we hope to bridge the gap separating the microworld of individual patient visits and the macrouniverse of health policy.
The book is primarily written for health science students—medical, nursing, nurse practitioner, physician assistant, pharmacy, social work, public health, and others—who will benefit from understanding the complex environment in which they will work. Physicians feature prominently in the text, but in the actual world of clinical medicine, patients’ encounters with other health care givers are an essential part of their health care experience. Physicians would be unable to function without the many other members of the health care team. Patients seldom appreciate the contributions made to their well-being by public health personnel, research scientists, educators, and many other health-related professionals. We hope that the many nonphysician members of the clinical care, public health, and health science education teams as well as students aspiring to join these teams will find the book useful. Nothing can be accomplished without the combined efforts of everyone working in the health care field.
Understanding Health Policy attempts to explain how the health care system works. We focus on basic principles of health policy in hopes that the reader will come away with a clearer, more systematic way of thinking about health care in the United States, its problems, and the alternatives for managing these problems. Most of the principles also apply to understanding health care systems in other nations.
Given the public’s concerns about health care in the United States, the book concentrates on the failures of the system. We spend less time on the successful features because they need less attention. Only by recognizing the difficulties of the system can we begin to fix its problems. The goal of this book, then, is to help all of us understand the health care system so that we can better work in the system and change what needs to be changed.
In our attempt to unify the overlapping spheres of health policy and health care encounters by individuals, we use clinical vignettes as a central feature of the book. These short descriptions of patients, physicians, and other care-givers interacting with the health care system are based on our own experiences as physicians, the experiences of colleagues, or cases reported in the medical literature or popular press. Most of the people and institutions presented in the vignettes have been given fictitious names to protect privacy. Some names used are emblematic of the occupations, health problems, or attitudes portrayed in the vignettes; most do not have special significance.
In exploring the many controversial issues of health policy, our own opinions as authors inevitably color and shade the words we use and the conclusions we reach. We present several of our most fundamental values and perspectives here.
We believe that health care should be a right enjoyed equally by everyone. Certain things in life are considered essential. No one gets excited if someone is turned away from a movie or concert because he or she cannot afford a ticket. But sick people who are turned away from a medical practice can make headlines, and rightly so. A simple statement of the right to health care reads something like this: All people should have equal access to a reasonable level of appropriate health services, regardless of ability to pay.
In 2009, the United States entered into a fierce debate over whether health care should be a right. The debate focused on President Barack Obama’s campaign to enact universal health insurance. Following a year of public ferment, Congress passed the Affordable Care Act, which goes a long way toward guaranteeing health care as a right. Yet, at the time of writing this edition of Understanding Health Policy, the controversy continues with challenges to implementation of the Affordable Care Act.
We believe that limits must be placed on the costs of health care. Cost controls can be imposed in a manner that does relatively little harm to the health of the public. The rapidly rising costs of health care are in part created by scientific advances that spawn new, expensive technologies. Some of these technologies truly improve health care, some are of little value or harmful, and others are of benefit to some patients but are inappropriately used for patients whom they do not benefit. Eliminating medical services that produce no benefit is one path to “painless” cost control (see Chapter 8).
Reduction in the rapidly rising cost of administering the health care system is another route to painless cost containment. Administrative excess wastes money that could be spent for useful purposes, either within or outside the health care sector. While large bureaucracies do have the advantage of creating jobs, the nation and the health care system have a great need for more socially rewarding and productive jobs (eg, home health aides, drug rehabilitation counselors, childcare workers, and many more) that could be financed from funds currently used for needless administrative tasks.
There is a growing consensus that health care cost increases are bad for the economy. Employers complain that the high cost of health insurance for employees reduces international competitiveness. If government health expenditures continue their rapid rise, other publicly financed programs essential to the nation’s economy (eg, education and transportation) will be curtailed and the unsustainable government budget deficits will strain the future of the nation’s well-being.
Rising costs are harmful to everyone because they make health services and health insurance unaffordable. Many companies are shifting more health care costs onto their employees. As government health budgets balloon, cutbacks are inevitable, generally hurting the elderly and the poor. Individuals with no health insurance or inadequate coverage have a far harder time paying for care as costs go up. As a general rule, when costs go up, access goes down.
For these reasons, we believe that health care costs should be contained, using strategies that do the least harm to the health of the population.
Most physicians, nurses, and other health professionals are trained to provide clinical care to individuals. Yet clinical care is not the only determinant of health status; standard of living and public health measures have an even greater influence on the health of a population (see Chapter 3). Health care, then, should have another dimension: concern for the population as a whole. Individual physicians may be first-rate in caring for their patients’ heart attacks, but may not worry enough about the prevalence of hypertension, smoking, elevated cholesterol levels, uncontrolled diabetes, and lack of exercise in their city, in their neighborhood, or among the group of patients enrolled in their practices. For years, clinical medicine has divorced itself from the public health community, which does concern itself with the health of the population. We believe that health caregivers should be trained to add a population orientation to their current role of caring for individuals.
We could not have written this book by ourselves. The circumstances encountered by hundreds of our patients and dozens of our colleagues provided the insights we needed to understand and describe the health care system. Any inaccuracies in the book are entirely our responsibility. Our warmest thanks go to our families, who have provided both encouragement and patience.
Earlier versions of Chapters 2, 4, 5, 8, 9, and 16 were published serially as articles in the Journal of the American Medical Association (1994;272:634–639, 1994;272:971–977, 1994;272:1458–1464, 1995;273:160–167, 1995;274:85–90, and 1996;276:1025–1031) and are published here with permission (copyright, 1994, 1995, and 1996, American Medical Association).
This is a book about health policy. As such, we will cite technical studies and will make cross-national generalizations. We will take matters of profound personal meaning—sickness, health, providing of care to individuals in need—and discuss them using the detached language of “inputs and outcomes,” “providers and consumers,” and “cost-effectiveness analysis.” As practicing physicians, however, we are daily reminded of the human realities of health policy. Understanding Health Policy: A Clinical Approach is fundamentally about the people we care for: the uninsured janitor enduring the pain of a gallbladder attack because surgery might leave him in financial ruin, or the retired university professor who sustains a stroke and whose life savings are disappearing in nursing home bills uncovered by her Medicare or private insurance plans.
Almost every person, whether a mother on public assistance, a working father, a well-to-do physician, or a millionaire insurance executive, will someday become ill, and all of us will die. Everyone stands to benefit from a system in which health care for all people is accessible, affordable, appropriate in its use of resources, and of high quality.
Thomas Bodenheimer
Kevin Grumbach
San Francisco, California
February, 2012