No matter who wins next week’s presidential election, the challenges of health care delivery in the United States— rising costs, uneven quality and limited access—will lead to unprecedented changes in the way health care is delivered, managed and paid for in coming years, according to former Senate Majority Leader Tom Daschle.
“This is arguably the most transformative moment in health care in this nation in 200 years,” said Daschle, a distinguished expert in health policy and a Democrat from South Dakota, who was the featured speaker at the the12th Annual Marshall J. Seidman Lecture on Health Policy on Oct. 30.
Daschle said the changes American consumers are seeing as a result of the Affordable Care Act, and the challenges that it still has to overcome, will alter health care in the U.S. more than the creation of Social Security, Medicare or Medicaid.
“The gravity of the time cannot be overemphasized,” Daschle said.
To meet these challenges, he said, health care policymakers will need resilience, innovation, collaboration, an engaged citizenry and strong leadership.
Medical students and physicians will play an important role in the transformations ahead, Daschle said, adding that as a South Dakotan he would love to see Harvard Medical School graduates choose to take up primary care and internal medicine in more rural states where such basic care is badly needed.
He also stressed the need for overall efforts to build a foundation for public health, with growing emphasis on wellness, preventive care and primary care.
In addition to creating greater incentives for physicians to pursue careers in primary care, Daschle noted the need for an increased role for nurses, nurse practitioners and physician assistants.
In his lecture, sponsored by the Harvard Medical School Department of Health Care Policy, Daschle outlined the challenges that remain ahead for the Affordable Care Act, listing a series of actions that Gov. Mitt Romney might take if he is elected, including attempting to repeal the ACA and generally limiting the federal role in health care. He said Romney would likely move more decision-making power to the states, and might empower business to effect the necessary changes to the system.
Daschle also catalogued a series of challenges that remain to be overcome for full implementation of the ACA if President Barack Obama is reelected, including ongoing legal, legislative and budgetary challenges to the act. He also focused attention on the remaining changes that need to be made, regardless of the outcome of the election.
The complicated American health care marketplace does not work as an integrated system, and places too much emphasis on high-technology interventions and not enough on primary care and preventive medicine, which should be the base of the health care pyramid, Daschle said.
“Most societies start at the bottom and build up. We start at the top and build down until we run out of money,” Daschle said. “We don’t have a foundation of wellness.”
Daschle noted that there is wide agreement on the nature and causes of the current crisis, and even on the goals of reform.
The main obstacles to reform are that the two political parties have a substantial disagreement about what should be the role of government in solving these problems, he said, and that they are currently entrenched in a politically confrontational environment with little room for compromise.
One of the roots of the current crisis, Daschle added, is a lack of transparency.
“We have more statistics on any sports player in this country than we do on our health providers and our hospitals,” Daschle said.
In spite of many high-quality institutions and practitioners, he said, we have a quality problem: “We have islands of excellence in a sea of mediocrity,” he said, citing studies that show 100,000 people die each year because of medical mistakes.
While the U.S. health care marketplace comprises nearly 17 percent of GDP, it is one of the most complicated and one of the least transparent markets in the economy, he said, and the fee-for-service system encourages medical practices to act like businesses, rewarding volume instead of value.
The ACA attempted to address questions of access and quality, and is an important step in the right direction, Daschle said, although it has many flaws.
“In this republic, in particular, as divided as it is right now, that’s what you get,” he said.
Also, no matter how the election is decided, Daschle said, the country still faces a huge debate about how we control health spending. He said the only real choice is to redesign and improve all aspects of health care delivery, borrowing a turn of phrase from Don Berwick, HMS lecturer on health care policy, senior fellow at the Center for American Progress and former administrator of the Centers for Medicare and Medicaid Services.
As unsustainable growth of costs mounts, Daschle said he would like to see the creation of a “Health Fed,” something like the Federal Reserve that could manage health marketplaces outside of the politically charged atmosphere of Congress.
He acknowledged that this scenario seems unlikely now, but if the alternative becomes a single payer, universal health care system run by the government, conservatives may prefer a managed marketplace.
“Don’t think that the status quo today will be the status quo in 15 years,” Daschle said.
Daschle, who was elected to the U.S. House of Representatives in 1978 and served four terms in the House before being elected to the Senate in 1986, rose to the top Democratic leadership position in the Senate in 1994 and served in that role for more than a decade.
The former senator has followed the political struggles around health care and health reform for decades, but is optimistic that the nation will overcome the challenges it faces.
In closing, Daschle shared Winston Churchill's famous quip that, “Americans will do the right thing after they have tried every other possibility,” and an observation from Nelson Mandela’s autobiography, Long Walk to Freedom: “Many things seem impossible until they’re done.”
Daschle said he finds inspiration in those words, and is optimistic about the future.
“Health care reform has long seemed impossible,” Daschle said, “but I believe we’re on the cusp of getting it done.”
Daschle joined a distinguished group of leaders and experts who have delivered the Seidman Lectures since 2000. Former speakers include Alan Weil, Executive Director of the National Academy for State Health Policy, Peter R. Orszag, Director of the Congressional Budget Office, and Lawrence Summers, former U.S. Secretary of the Treasury and President of Harvard University. See this link for a complete listing of past speakers.
