A Harvard interfaculty program Tuesday (April 11) recommended sidestepping federal paralysis on health care reform by fostering innovation in states and towns in a process that would eventually spread the best ideas across the nation.
David Blumenthal, chairman of the Harvard Interfaculty Program for Health Systems Improvement, said that despite a growing consensus that the nation’s health system needs significant changes to improve quality, cut costs, and increase coverage, there is little chance that the federal government will be able to approve national reforms.
“These problems are universal. … For the first time in my lifetime this experience is seeping into the middle class. People’s grown children leave school and can’t find health insurance,” said Blumenthal, Samuel O. Thier Professor of Medicine and professor of health care policy. “There’s a realization that everyone is rolling downhill to a cliff, though most aren’t there yet.”
The absence of federal action, coupled with a history of innovation at the state and local level, led the Interfaculty Program on Health Systems Improvement to propose a plan that puts the onus of solving the nation’s health care problems on state and local governments while the federal government assumes a supporting role.
The plan, set out in a report titled “A Strategy for Health Care Reform: Catalyzing Change from the Bottom Up,” envisions a phased approach over the next 20 years that would explore different ways to address health care problems and allow a national consensus for change to build.
The report describes the current system as “dysfunctional” and “out of control” and says that there’s a growing consensus that something must be done. The problem, however, is that there is an enormous disagreement over what that should be. And, absent consensus on how to solve the problem, the report says, it will remain unsolved.
The report sets out ambitious goals for the U.S. health care system in several areas including cost, quality, and access. Among those goals are:
- Universal health care coverage in 20 years. The report says that 45 million Americans were without health insurance in 2003, 9.1 million of them children. The report envisions a phased approach to achieve that goal, with all children under 18 covered in five years, all adults over 55 covered in 10 years, and 100 percent coverage in 20 years.
- A reduction in medical errors by 85 percent in 20 years, along with elimination of ethnic and racial disparities in chronic illness management.
- Increasing the affordability of health care to reduce the likelihood that treatment will drive patients into bankruptcy. The report sets the goal of reducing the number of health-care-related bankruptcies by 95 percent over 20 years, along with a 95 percent decline in the number of people who say they don’t have health coverage because of its cost.
- Keep the growth in health care expenditures to 2 percent annually.
- Attack obesity, smoking, and asthma to reduce the growth of chronic health problems. Reduce the number of obese and overweight U.S. adults from 65 percent to 50 percent and overweight children from 16 percent to 11 percent over 20 years. Reduce the percentage of U.S. adults who smoke from 22.5 percent to 12 percent in 20 years. Reduce hospitalizations and emergency room visits for asthma.
To achieve these goals, the report proposes a 20-year, three-stage process that both encourages innovation and seeks to build a national consensus for change.
The first stage would support and stimulate existing efforts to improve the health care system at the state and local level. The federal government would stimulate this process by offering matching federal seed money to get programs started and strengthen current federal efforts such as health savings accounts, tax credits, and medical litigation reform.
The second stage, beginning in five to 10 years, would phase in a state-centered approach where 10 states would be selected to receive federal funding to implement plans that further national health goals. The states would work to expand health insurance coverage and achieve gains in quality, cost, and the health status of their population. At the same time, the federal government would adopt national health care goals that could be achieved over a 20-year period. A goal for stage two would be to cut the number of uninsured in the country from 45 million to 30 million within 10 years. Other goals would be set in areas such as value, affordability, and population health.
The last stage of the plan, to begin in 15 to 20 years, would implement the best state-based programs developed in stage two throughout all 50 states.
The report came together after hearing testimony over the past several years in the Harvard Forums on Health, held around the country to explore attitudes about health care and solutions to health care problems.
“We came away very encouraged that so much was happening in the absence of federal support,” Blumenthal said.
Though it may seem the plan was born of frustration with federal inaction, Blumenthal said that it’s not really unusual for the federal government to be unable to move on such a major issue. Many major reforms, from the initial adoption of Medicare to the welfare reforms of the 1990s, moved forward at the state level first, he said. In a nation with a strong tradition of local control, innovation beginning at the bottom and moving up is not unusual.
“We … think there’s a lot of trial and error that has to occur in the local community before [national reforms],” Blumenthal said.