Q&A: Health Bill Called 'Good Start'
This is the first in a weekly series of interviews with health-care professionals in the area who offer differing perspectives on the debate over health-care reform.
The Affordable Health Care for America Act, passed by the House of Representatives on Nov. 7, is "a very good start" toward reforming the American health-care system, says Dr. Lori Heim.
Heim, a hospitalist and the president of the American Academy of Family Physicians (AAFP), concedes that the legislation isn't perfect, but says it makes a strong effort to provide health insurance to nearly every American and takes measures to reform the insurance market -- two elements she considers to be essential to true reform.
She argues that the debated "public option" for health insurance would provide for competition in the insurance market and says the public plan would not have an unfair advantage over private insurance companies.
In October, Heim was among a group of physicians on hand for a ceremony at the White House Rose Garden. She also participated in a briefing with the president in the Oval Office.
Heim spoke with Staff Writer John Krahnert. Here is an edited transcript of the recorded interview.
Q: Could you just tell us a little bit about your background?
A: I started in the U.S. Air Force and retired after 25 years of service, through medical school and as a physician -- family-medicine trained. I then went into private practice here in Pinehurst. And when I was elected as president-elect at the AAFP, I then took a position as a hospitalist down in Laurinburg at Scotland Memorial Hospital.
Q: Health-care reform is the big debate in the country right now. Everybody's talking about it. Could you explain what's wrong with the current health-care system?
A: Well, if you compare our system to every functioning health-care system, there are a few critical components that we're lacking. One is that we have a system -- if you can even call it a system -- that is terribly fragmented, which leads to problems with quality, leads to duplication of efforts and is associated with many of the problems we see regarding patient safety.
So you have a fragmented system, and you have a mismatch of primary care-based to subspecialist-based. And I'm not even talking about whether or not you have a single-payer or not, I'm just talking about if patients have insurance, if they have access to a primary-care physician who coordinates care.
From our standpoint, health-care reform has to address the fact that people don't have insurance, or they're underinsured -- which is a huge issue in this country. They don't have access to primary care, to comprehensive care. And we have a work shortage -- a workforce inequity that really leads to suboptimal care for too many people.
Now there's no doubt that within this country there are areas of excellence when it comes to medical care. So, when we talk about health-care reform, obviously we want to retain those areas of excellence.
But, right now, we have rationing of health care, and part of what we want is to go back to "rational" health care, not "rationing," and what you have now is an economic rationing, or even besides economic access, there's the problem of geographic, racial and ethnic disparities in health care.
Q: What are they key elements of health-care reform in your eyes? What has to happen for the system to really work?
A: You've got to get to insurance coverage for all. Obviously, if you look at any of the bills going through Congress, we're talking about incremental changes. But we've got to get started on that road.
And I don't want to get into the debate about illegal aliens -- our Academy has called for health care for all Americans without reference to their status, only because currently -- illegal or legal -- they get health care, and unfortunately they often go the emergency room, which is the most expensive sort of care.
But the House bill right now will ensure that approximately 96 percent of Americans will be covered by health-care insurance. It maintains the current employer-based health care. It still creates a competition.
So besides providing health-care insurance, then the next thing that you have to have is insurance market reform. There are innumerous examples -- both within my practice and with all the members that I talk to -- of problems with insurance. And that goes back to what I said about "underinsured." You may have insurance, but if you have any sort of event, people often find that they are underinsured, and so their coverage really isn't what they expect.
Then, on top of that, is the insurance affordable? If you look at the insurance premiums that people are paying, those keep escalating. However, people complain that what's covered is declining.
If somebody gets sick, or even if their children get sick, they may either find that they are now facing premiums that they can't afford, or they may be dropped. And so, when we talk about market insurance, it's making sure that it's fair, that you cannot be denied because of a pre-existing [condition].
There also should not be lifetime caps. If you get seriously ill, you may find that your insurance runs out, and it doesn't matter how many years of premiums you've paid in. And we think that's unfair.
The other component is that if you're in certain age groups, your premiums are based not only on just what sort of health you are in, what sort of medical problems you have or how you take care of yourself, but simply based on your sex or your age. The House bill and the Senate bill both address that in terms of how much they can charge simply because of an age difference, and we think that makes it much fairer.
Q; If you were the "health czar" for a day and could enact any system you wanted to without any debate, what would you choose?
A; Personally, I think that a single-payer system, such as I practiced under in the Air Force, provides the most savings for the country in health-care dollars and gives the best protection for people. But that's not a political reality, and even if I could enact that, there would be such an uproar that we know that that's not practical.
My own Academy's views are that we need to have a multi-payer. Much of this is because that for America, we still value competition, and, to a certain extent, want to have the market drive competition. My concern is that our current market-driven strategy leaves too many people without affordable, fair coverage.
Q: What are your impressions with the Affordable Health Care for America Act recently passed by the House of Representatives? Does it do enough in your eyes, or does it leave out key elements?
A: It leaves out many elements. It's not perfect, but it's certainly a very good start. That bill, House Bill 3962, will provide coverage for 96 percent of the public. So it makes a good start for getting health insurance for everyone.
It does have insurance market reforms, so it begins to take a look at making that fair and affordable. And it does provide for a public option. In some markets, you may not need to have competition. But in other markets throughout the country, there simply is no competition. Whether or not you're a citizen or you're a physician, you essentially have one or maybe two at the most.
We also see that that bill has a recognition of the need for primary care. It has an increase in payment of 5 percent for primary care physicians. It's 10 percent if they're in an underserved area, which obviously isn't enough to decrease the disparity between primary care physicians and specialists, but it's a recognition and it's a good start.
Q: The public option debate has become really contentious. Why is having a public option important, in your opinion?
A: You know, I find this debate about the public option so interesting. One of the first things people usually say to me is that they don't like anything government-run, that the government can't run it well. But then on the other hand, they tell me the public plan, government-run, will be run so well that it's going to run all the private insurance out of business. So those two things don't match up in my mind.
The other thing is, I'll turn to Medicare, which is a government-run health plan. After being in private practice and my time in the military, I'll tell you there are not too many seniors who want to give up their Medicare. They like it. So one of the suggestions initially was to simply expand Medicare.
The public option is another way of providing insurance. That's all it is. What the bills are looking at is making a big insurance exchange, and in that exchange, you can pick from A, B, C, D, E -- private insurance companies -- and F might be the public plan.
But what they've done is said, "OK, if you're going to be in this exchange, then you have to meet certain minimums." So, again, market reform, you can't dump people because they've gotten sick, you can't jack up the premiums, etc.
So what they're trying to do is make sure that there is competition. Now CBO (the Congressional Budget Office) estimates that 6 million people will go into the public plan option. The only way that that would run out other insurance plans, to my mind, are if those are insurance plans that are poorly run -- in which case, when did we start saying we're going to prop up a private company that's poorly run, notwithstanding some of the recent bailouts that we've had?
But I would hate to see us now continuing bailouts for private health-insurance companies.
Will there be some small insurance plans that go out of business? That's possible, I've heard some projections of that. But that doesn't mean that we're going to run all of them out, nor do I think that this is any sort of plan or grand scheme to do that. The way that the bills are being constructed, the public plan option will have to compete. It will not get any special deals.
Q; It seems the tort reform issue has kind of been swept under the rug. Could you touch on that aspect?
A: Tort reform, I think, is actually much more complicated an issue than most of the media has covered -- and the debate among physicians as well. If you look at states that have enacted pretty stringent, noneconomic caps -- which is what most physicians want, Texas for example -- and you look at their cost of medical care, you actually don't see a decrease. Not a significant one. In fact, some parts of Texas are some of the highest-cost in the nation. So if simply putting in noneconomic caps was the magic bullet, we should have seen that in Texas.
What it did do, however, was it really did manage the malpractice premiums for physicians, and Texas was losing a lot of subspecialists to other states, which they have now rebalanced.
The notion of malpractice insurance leading to a change in physician behavior to not do "defensive medicine" has some merit, but I don't think we have a really good understanding of how much impact it truly would have. And the literature and CBO scoring is sort of all over the board. What you have is probably a training issue that needs to be addressed as young physicians come along, but no one wants to miss something. So I think that in large part, that drives a lot of this, as opposed to a fear of litigation.
Q: Are there any other issues in the health-care debate that you don't think are getting talked about enough?
A: I don't think the press necessarily has understood that if we're going to make this investment in our health-care system, we have to construct a system that deals with prevention. That's how you get long-term system savings.
The House bill does that by removing the cost for preventive screenings and services.
That's huge, because people don't go in now sometimes because of the co-pay, and that's where you gain downstream savings.
I would much rather prevent a heart attack or prevent kidney failure than end up having to pay for expensive technology later or dialysis later. That just makes sense. That's where you make the investment.
The other big thing that is going along with this is, the House pulled out the Medicare SGR -- it's the formula that they use to determine physician payment -- which has been flawed over the years, and Congress just has not addressed that. As we move forward, both the House and the Senate are trying to take a look differently at how they are going to fix it.
Q: Anything else you'd like to add?
A: You probably don't know about it, but within the bills -- both the one that the House passed and the Senate bill -- there's provisions for pilot testing what's called the "patient-centered medical home." That is a model of new delivery of primary care that really looks at a team approach, which focuses on the patient and the relationship with the physician, that has been endorsed by all of the primary care organizations to improve the quality of primary care delivery, and we think it will also encourage lower costs.
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