This is the third in a weekly series of interviews with health-care professionals in the area who offer differing perspectives on the debate over health-care reform.

Dr. Bussey Favors Reform Legislation

Whether the United States should pursue health-care reform is a moral question at the end of the day, according to Dr. George Bussey.

Bussey, a psychiatrist by training, is the chief medical officer at FirstHealth of the Carolinas. He's been with FirstHealth since 2001, when he moved here from Hawaii. He generally favors the kind of health-care legislation now making its way through Congress.

Bussey considers access, costs and quality of outcomes to be the three essential elements of health-care reform. He says the United States is the only developed, modern nation that doesn't view health care as a right for every citizen. He says it is time to do something about the warnings for two decades that people die from not having health insurance.

He supports the health-care legislation slowly making its way through Congress and thinks the public option provision under debate could help provide for competition in the insurance market in certain areas. Eliminating caps and pre-existing conditions are also paramount, he says.

Bussey recently spoke with staff writer John Krahnert. Below is an edited transcript of their interview

Q: Could you tell our readers a little bit about your background?

A: I came to Pinehurst and FirstHealth in the summer of 2001. I am a psychiatrist by clinical training and had lived in Hawaii for 20 years before coming here. In Hawaii, I had worked in private practice, psychiatric hospital administration, and then also worked as medical director for a group of health plans, not too dissimilar from what Mr. [Ken] Lewis [president of FirstCarolinaCare, interviewed by The Pilot in last week's Q&A] does here. It was a group of health plans operated by the largest health system in the state.

While I was in Hawaii, I also got my J.D. degree. After I came here, I had spare time on my hands again for some reason or another, went back and also got a master's in health-care administration.

Since I've been here, I started out in the behavioral area and then took over as chief medical officer.

Q: Health-care reform is the big political issue today. What do you think is wrong with the current system that necessitates this reform movement?

A: I think what's wrong with our system is that we're the only modern, industrialized country in the world that doesn't treat health care as something every citizen has a right to have access to. I think it's basically a moral question at the end of the day.

Q: What do you think are the key elements of true health-care reform?

A: Clearly, access. People have to be able to get to the care.

Clearly, cost from the standpoint of both the person who's using the health care and whoever it is that's paying for the health care.

And then, I think the third part is the quality. The outcomes. Are we really getting what we've finally gotten access to and are now able to pay for? Are we truly getting a benefit out of it?

Q: What are your impressions of the bill that was passed by the House a couple of weeks ago? In your opinion, does it do enough?

A: I think it's a good start. I think that a lot of the things that people don't talk a whole lot about are nonetheless very important. I think Dr. [Lori] Heim [The Pilot's first participant in the health care Q&A series] talked about some of these as well -- the elimination of lifetime caps, the elimination of pre-existing conditions, some of those kinds of things I think are key.

I think the creation of the health insurance exchanges is important. As much as people moan and groan and go back and forth over the public option, I think that's an important part of something that needs to be there.

I always find it interesting, as did Dr. Heim, [the allegation] that the government that can't do anything right will somehow be able to out-compete with private insurance. And I think there probably are some appropriate safeguards that might need to be put in there to make sure that any actuarial or financial or other kinds of benefits don't accrue to one side of that competition or the other. But I think if you make it a level playing field, I think that would be a good thing to have there.

Q: Why is the public option such a hot-button issue?

A: Well, one theory about why it's a hot-button issue for conservatives is that, what if it actually worked really well? What if it actually worked like Medicare and like Medicaid and most people were actually quite content with it? What might that say about the necessity or appropriateness of for-profit health insurance companies?

I think conservatives, and people on the more conservative end of the spectrum, tend to think that it is some kind of gateway to a British style of health care, where the state owns and runs the system. But I think the reality is that in most Western and/or industrialized countries, that's really the minority system, if you will, for providing health care to everybody. Germany doesn't use that kind of system, Switzerland doesn't use that kind of system -- although if you need some kind of public option or government guarantee, it's usually there in the background.

I don't think the way it's put together in either the Senate or the House bill that this is the road to a British style of health-care delivery or even a Canadian style.

Q; Why is it important to have government involvement in health care, in your opinion?

A: Because ultimately, the government's already involved. Right now, Medicare is a government program, in a sense that it's funded through a Medicare tax. That tax goes to help pay private hospitals and private physicians to provide health care.

Medicaid is a joint venture between state governments and the federal government. Military health care is government health care. The VA is government health care.

What controls currently exist on the way insurance companies operate is related to government intervention. One of my experiences in Hawaii when I was working on the health plan side of the business was that we actually ended up taking over a failed insurance company because they had inadequate reserves. The state had to step in and take over receivership and essentially guarantee payment, and then find another health plan to manage that.

If you didn't have government rules and regulations about what kind of reserves insurance companies had to keep, what kind of rules they had to use for appeals of denials, things like that, it truly would be a totally "buyer beware" kind of market, where the knowledge and information differential between the people selling the product and the people trying to buy it would be so significant that it would be a very unequal kind of bargain to be engaging in.

So the government is involved in any event.

I think the other reason is that, kind of getting back to your first question, every other modern, industrialized country has accepted the fact that health care for its citizens is a key to the success of their economy, and a moral commitment, a moral contract if you will, with their citizens.

When you're a very small clan or society, you can kind of count on the folks you know to help you out. At the end of the day, sitting out in the waiting room is the rest of the community, and whatever the bill is, they all chip together and pay for it. That works in a small society. When you have 300 million people, you don't have the ability to behave in that way. We have governments and we have those kinds of structures for a reason. Because when you get big enough to provide certain kinds of services, whether it's law enforcement or fire protection or public education, you need a systematized process.

So I think that's one of the reasons that having the government involvement is there.

As I said, you go to a country like Switzerland or Germany, where they structure their insurance industry differently, there you probably don't need a pure government option as much because you have 200 insurance companies to choose from, if you're in Germany. Pick any one you want.

People don't have those kinds of choices as much around here. Where I came from, Hawaii, the Blue Cross/Blue Shield affiliate had about 65 percent of the business, Kaiser had another 15 or 20 percent of the business, and there were the two or three little guys, like we were. That's pretty close to a monopolistic kind of situation.

Q: So the public option is important to creating competition?

A: I think so.

Q: You mentioned that this legislation is a "good start." What does it leave out?

A: The third part of those three things I mentioned [quality]. I think as much as health-care reform in general is sort of the third rail of politics right now, certainly getting into payment reform and looking at the quality of the outcomes and how we pay for things is kind of the ultimate third rail of the process, because at that point you're doing two things.

One, you're going to have an impact on what people make. And two, you're going to call into question what nobody really likes to call into question, which is the belief that our entire country is made up of doctors from "Lake Wobegon" -- they're all above average, everybody is excellent, all hospitals provide great care. And the reality is, there is variation, and a lot of the variation is not explainable by clinical variation in the patient that presents to you.

Until we figure out a way to actually reward physicians and facilities for providing good outcomes, it's going to be really hard to manage the costs of things.

Q: What aspects of health-care reform are the public not picking up on?

A: I think a lot of the good and less controversial things that are in the bills -- the removal of the caps, the no-pre-existing-conditions eliminations -- those kinds of things are really key.

On one side of the political spectrum, you have people who have just kind of got it in their heads that any bill is bad. Then on the left side of the spectrum, you have some people who think a bill without a public option shouldn't be passed. As much as I'm a supporter of having that in there for competition purposes, the risks that would present to our country of allowing us to not have any change going forward is just too significant.

I think we have to get some form of meaningful reform through the system.

Q: Is it fair to say you're supportive of this legislation?

A: Yes.

Q: Do you think it will get through the Senate, or is that too hard a question?

A: You know, everybody you talk to who's supposed to know the answer to that has a different answer. Some people say its DOA. Some people say they'll get it through on reconciliation and it'll have the public option in it. Some people say they'll drop the public option.

We'll see. I do think something will pass. I don't know what it will end up looking like in the end.

Q: Anything else you'd like to add?

A: A couple of things, I guess.

One, we know that people die from not having health insurance. We knew it 20 years ago. We know it again now. So, again, I don't like to be a moralistic kind of person.

But just from the standpoint of if we're truly talking about the value of human life, we have to do something. Whether it's 25,000 lives a year or 44,000 lives a year, that's a lot of lives.

I think the other thing that is important for people to understand is the way in which our inability to address the cost of health care has adversely affected the individual economic well-being of each and every one of us.

Generally speaking, health insurance is paid by your employer. So if every year, on average, health insurance premiums are going up 6, 7, 8, sometimes 12, sometimes 15 percent a year, somebody's paying for that. And the somebody who's paying for most of that generally is your employer, and if your employer is paying that kind of money on increased benefits, that's money that he or she can't sit down across a table and negotiate with you on in terms of other benefits, or salary increases or anything else.

Look at what's happened to middle-class incomes over the last 20 or 30 years.

They haven't moved a whole lot. But you look at what portion of an employer's business expenses are going toward health insurance, and you think, "Whoa! That was sort of a transfer of wealth there. I'm not sure as a working person I'd like to have all that money going that direction, when maybe we could have done something to contain the system and get it to work a little bit more efficiently."