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As the national debate over health care rages, we’re asking Schweitzer Fellows and Fellows for Life — who are working directly with the populations whose needs are unmet under our current health care system — to weigh in.

2007-08 Schweitzer Fellow Zirui Song; Former US Surgeon General Dr. David Satcher.

(Photo credit: Tom Baran) 2007-08 Schweitzer Fellow Zirui Song; Former US Surgeon General Dr. David Satcher.

In our first installment, we hear from 2007-2008 Boston Schweitzer Fellow Zirui Song (pictured above with former U.S. Surgeon General David Satcher at ASF’s May 9 symposium and concert). As a Fellow, Zirui collaborated with the Brookside Community Health Center in Jamaica Plain to develop a youth sports program as part of a comprehensive approach to encourage pediatric patients to adopt a healthier and more physically fit lifestyle. Now a Year IV MD/PhD student in Health Policy at Harvard Medical School, Song shares his thoughts on health care reform below:

Much of the debate over national health care reform has focused on President Obama’s “public option”—a government-run health insurance plan that would compete with the private insurance industry. The politics of this debate has dominated media coverage on health care.

Supporters of the President cite the importance of a public option in achieving universal coverage. By offering an affordable insurance option accessible to all Americans, it would serve as the practical centerpiece of any proposed individual or employer mandate. Competition with private insurers would keep the price of health insurance low across the market, enabling people to purchase health insurance with the aid of subsidies based on household income.

On the floor of the Senate, Majority Leader Harry Reid compared the public option to the U.S. Postal Service, which provides cheap, basic services while competing with private companies such as FedEx or UPS. In a 6/20/09 New York Times/CBS poll, 70% of Americans favored a public option.

Opponents say that a public option would mean longer waits at the doctor’s office, rationed care, and the government standing between you and your doctor. In Senate Health Committee hearings, Republicans also pointed to the plan’s projected costs, which the Congressional Budget Office estimates to be as high as $1.6 trillion over ten years.

In his speech to the American Medical Association last week, President Obama outlined where this money would come from, including savings generated by more preventive care and the use of electronic health records. But opponents have pressed on, arguing that such ambitious spending is unrealistic in this economy.

As the political battle unfolds, it is often easy to forget that at its core, health care reform was born not of disagreement, but rather a set of four principles that most people agree on. They are, roughly, as follows:

  •  First, we are a nation which should not tolerate 47 million people living without health insurance — so providing coverage to the uninsured is necessary.
  • Second, the explosion in health care spending, now 17% of GDP, is not sustainable for families, businesses, or state and federal governments — so slowing this growth is necessary.
  • Third, the quality of health care delivered to Americans is often suboptimal — so improving the quality of care is necessary.
  • And fourth, disparities in care across geography, race, education, income, and other socioeconomic determinants of health continue to plague our health care system with unequal outcomes for otherwise equal people — so eliminating disparities is necessary as well.

Over the past 20 years, hundreds of studies have documented the extent of health care disparities. African Americans, for example, consistently receive fewer appropriate treatments and experience greater mortality risk across leading causes of death, including cardiovascular disease, cancer, and diabetes compared to white Americans. But only within the past decade has research confronted the more difficult task of determining effective interventions.

I believe the single most important issue that meaningful reform must address is how to design policies that increase the quality of care across different groups while decreasing cost. In principle, providing coverage to the uninsured is conceptually straightforward—we need money. In contrast, affecting the quality, cost, and equality dimensions is much more difficult, for many reasons. Chief among them is that these dimensions rest on people’s behavior, and behavior is difficult to change.

Physician behavior, for example, depends on patient preferences, payment systems, and clinical evidence, but it also depends on more amorphous and intangible things like practice style, the culture of physician groups, and practicing defensive medicine. The behavior of patients, too, is difficult to define, much less change with policy. The interplay of hope, fear, and trust within the doctor-patient relationship all help to determine the quality and quantity of care received, not to mention daily behaviors such as smoking, exercise, and nutrition.

Check back tomorrow for part two of Zirui’s thoughts on health care reform — and let us know if you agree with him by leaving a comment.

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