Conversations - Getting Healthy

Published in the Fall 2008 issue of SSA Magazine

The pressure to fix the U.S. health care system continues to grow as employers and individuals grapple with the increased cost and complexity of health care and health insurance policies, and as society grapples with rising numbers of individuals who lack health insurance coverage. For this issue's Conversation, we looked at which crucial issues for low-income communities should be addressed in health care policy discussions for the new administration soon to begin in Washington.

SSA Associate Professor Harold Pollack is a deputy dean at the School and faculty chair of the University of Chicago's Center for Health Administration Studies. He has published widely at the interface between poverty policy and public health and has been appointed to two committees of the National Academy of Sciences' Institute of Medicine. Dr. Tariq Butt is the deputy medical officer of Access Community Health Network, the nation's largest network of community health centers, which serves 215,000 individuals annually in underserved neighborhoods throughout the Chicago region. He is a family physician with teaching appointments at several local medical schools and serves on the Board of the Chicago Public Schools. Pollack and Butt sat down to talk in mid-September, before the election results.

Pollack: I think our health system has several major problems, and we're under a huge amount of pressure in the political process to claim that we are going to solve them all at the same time.

At last count, we're spending $2.1 trillion on health care in this country. Yet we have 45 million uninsured people and 78 million with significant financial issues around medical billing and medical debt. So protecting patients against catastrophic financial risks is something we're not doing very well, despite enormous expenditures. In terms of quality and cost effectiveness, we're falling far short, particularly in urban communities that are often overwhelmed. People in Chicago are fortunate to have an organization like Access, which I think provides a high quality of care in a very difficult environment. Yet you have 215,000 patients. We've got about a million uninsured people in Chicago who need similar quality services.

If you project out into the future, Medicare and Medicaid expenses are destroying state and local budgets and are putting big strains on the federal budget. If we cannot somehow either restrain the cost growth of medical care or find a different way to pay for the medical care that we demand, we've got serious problems looking forward. On the other hand, health care seems incredibly overpriced right up until the moment that you have a chest pain. As Americans, we know we get many good things in our health care that we don't want to put at risk. We want to maintain incentives for innovation. And so that's a further complication.

In America, we spend the most by far per capita on health care, but look at our infant mortality rate and virtually every other public measure. We're doing worse than countries that have half the per capita income we do and spend a lot less on health care.

Butt: I agree with you on these points. It's all true. I face these things as a provider in the most challenged neighborhoods in Chicago. And if you look at Access Community Health Network's spread of health centers, which are not all in urban settings—we are in Chicago Heights, Blue Island, Des Plaines, Addison, and other areas, including DuPage County—all these communities are facing these same issues.

Consider a pregnant mother who's unemployed or has a husband who may be under- or uninsured. The types of insurance that she and her family have can make her situation much more complex. If she has private insurance, she naturally will be accepted by most providers. If she has Medicaid, she may be treated as if she's an uninsured patient she may not find a local provider who accepts Medicaid because of its low level of reimbursement.

Pollack: Let me jump in on the reimbursement issue. We have a series of above-the-waterline issues that the average citizen sees—a crowded emergency room, people who lack coverage—but there's also another set of issues. Across the country, public officials are tempted to cut corners so they can get the money to respond to that public demand above the line. Everyone wants us to cover as many kids as we can, for example, which is incredibly important. But if you cover all the kids and provide low reimbursement rates to providers, you are going to create tremendous problems for those patients and for the people who take care of those patients.

Butt: At Access, we are committed to our mission of providing health care services to all who walk through our doors, regardless of that patient's ability to pay. We have developed a model that is payer blind. We pay [our doctors] based on quality and for the number of medical visits they provide, so our physicians are highly motivated to take care of the patient and they never have to look at the insurance. That's the kind of model I would like to see as a national health care model, one that has equity in terms of resources and access for patients.

Pollack: I think it's going to be a big challenge to achieve that, but I think it's a very reasonable standard. The function of public policy is to make sure that a model like yours is viable and can be expanded to reach the people who need it. One of the real challenges we have in health policies, though, is that health care is the most complicated ecosystem. It's one-seventh of our economy, and growing. All these pieces have to work together. Politically speaking, health care touches nearly every important interest group in America.

Butt: No one can do it alone. We have to really link to other organizations. We have partnered with the University of Chicago Medical Center, the Sinai Health System, and Northwest Community Hospital in Arlington Heights. We are also working with the Chicago Department of Public Health, the Chicago Public Schools, and the DuPage County Health Department, among other groups.

We try to create relationships and linkages to figure out ways to address these challenges. We see patients in the context of their whole lives: When a patient walks in and, as you look at their high blood pressure, you may find they need more than just medical help. They may also need a job. In these cases, our staff do all they can to link patients to local resources. We also hire many of our employees from the communities that we serve. This helps us link patients to resources right in their neighborhoods.

Pollack: Health care providers are a place where low-income patients can talk to a professional that they trust and get access to information. Where else in these men and women's lives are they getting that? Another part is down in Springfield, where they have a big role to play in making sure that we have an economic model that works.

Butt: Yes, absolutely. For example, Illinois offers the same Medicaid reimbursement for the specialists who work in our network, which is discouraging because the average specialist encounter costs more. So we have discussed setting an adequate [reimbursement] level with various state agencies.

But on the other hand, there are some state programs that have been very beneficial. For example, recently we learned about 250 women who had abnormal Pap smears, and their wait for Cook County services would have been prolonged and have possibly caused risk to the patient. But thanks to the Illinois Breast and Cervical Cancer Program and the statewide Stand Against Cancer Program, Access was able to provide timely care and link them to hospital resources.

Pollack: That abnormal Pap smear that takes an incredibly long time to respond to, that's a symptom of the stress that's on that system. If [Cook County's] Stroger Hospital is facing a huge burden of taking care of hundreds of thousands of uninsured people who otherwise have no other place to go, they're not going to have the resources that they need to get the right care to those women. Another example: We would like to see more public health screening done. It's very hard for providers to do that right now because they are crushed under the burden of so many underinsured or uninsured patients.

Butt: Absolutely. Cook County was able to take care of a lot of uninsured patients in the past, but now, because of tough economic times, their resources are scarce. From the patients' perspective, they walk in and they don't know whether they'll get the care they need in a timely fashion or if they may have to seek other resources. At Access, we now offer the same number of primary care visits in our system as provided by Cook County. It's great that we are able to provide quality, affordable medical care to patients in need. Yet so much more is needed if we are really going to address the needs of everyone in the area.

Pollack: Right. When we listen to the political health care debate, one might think we are debating whether or not to enact a National Health Service along the lines they had in Great Britain circa 1952. That's not what anybody wants in America, and I think probably rightfully so.

The composition of the insured population in America, though, is shifting more and more towards the public sector as the ultimate payer. Forty years from now, the private health care system in its current form will probably not exist. It is rapidly losing public legitimacy, and it's not designed to handle what's being asked of it. What is this going to transmute into? I think health care is so complicated that it's going to take us many, many generations to figure it out. Reforming health care is like trying to fix a ship that's cruising across the ocean. You have to fix some big holes without sinking the ship. That's a big challenge.