D.C. Dispatch: Pelosi Speaks

Today I’m in Washington, attending Health Action 2008. Families USA organized the event and invited me to come down and blog about it. Yesterday morning we heard Congresswoman Nancy Pelosi lay out her views on the health care issues facing Congress and I was both surprised and impressed by the strength of her speech.

Pelosi stressed equality: “We must fund bio-medical research,” she declared, “and the benefits must belong to every single American.”  She went on to point out that “in order to have this research available to all, we have to have a common electronic record—bringing everyone into the loop.” In other words, a single electronic medical record could provide the database everyone needs to see what works and doesn’t.

To be truly valuable, that database must be as broad as it is deep. As Pelosi put it, “the healthcare of the most privileged person in American benefits if everyone has health care, and if we have a common electronic record.”  (Pelosi also emphasized that this record must respect the privacy of everyone involved, keeping medical information about individuals confidential.)

She went on to say that while “bringing everyone into the loop, we must eliminate the disparities [in the quality of care that different groups in this country receive], not just from a sense of fairness—which would be justification enough alone—but in terms of insuring better health for the nation.”

“We need to have the workforce to do it,” she continued. “We need to support the education of doctors and nurses across disciplines because better teams provide better care. And that care has to be culturally appropriate [which means] knowing the language [of the patient], knowing the culture of [the patient]."

In other words, we need to draw our doctors and nurses from a broader pool of Americans, something I talked about in a post where I noted that only two students apply for every space in American medical schools.  To students coming from low-income families, medical school seems unimaginably expensive. As I suggested in a recent post, rather than paying some middle-aged specialists $800,000 a year—or more—we should use some of that money to subsidize medical school education for many, if not all, students.

Pelosi also argued that “healthcare must be personalized to the individual. The science and technology is there to make that possible.” At that point, I wondered, “But can we afford customized medicine for everyone?

Yet Pelosi made a compelling argument, insisting that “everyone should be getting state-of-the-art care. Forty-two percent of Americans with diabetes receive the right care; twenty-one percent receive the wrong care; and thirty percent receive no care. Everyone should be getting the right care. No one should receive no care”

She went on to give an example which illustrated that making sure that every patient gets the “right care” can mean giving some patients less care. “Of all the women diagnosed with breast cancer, half receive chemotherapy,” she pointed out. But depending on a woman’s age and other factors, chemotherapy may not be the best treatment for many women.  “A therapy that might work for another person might be absolutely wrong for me,” she explained.

Half of all women diagnosed with breast cancer probably shouldn’t be getting the same aggressive, potentially harmful treatment. “We have the technology to target who needs chemo,” Pelosi explained. “Just fifteen to thirty percent of women are likely to have a recurrence of the cancer.  Other women can be spared the unnecessary toxicity [of chemo.].

If customized care means targeting care so that some people get less care while others get more--based, not on what they can afford, but on what medical evidence culled from that huge electronic medical record tells us about what works best for certain types of patients—then, yes,  I agree with Pelosi. This is customized care that we can afford.

Pelosi ended her speech by returning to the theme that health care reform must mean providing “universal access to the best possible quality of care.”  When I think about health care reform my one great fear is that it will lead to two tiers of care. There is a real danger that politicians will decide that we can’t afford high quality care for everyone, so they will settle for something like Medicaid for low-income and lower middle class families—a poor plan for the poor.

The truth is that we can afford universal access to the very best care.   The $2.1 trillion that we are spending now is enough to do it. Switzerland does it for 60 percent of that amount.  (True, Switzerland has a more homogeneous population and many fewer people living in poverty, but the extra 40 percent is enough to cover our neediest citizens.  And of course, if we provided free, high quality preventive health care for the poor, over time they would become much healthier, and their long-term health care expenses would be significantly lower. )

But our healthcare dollars need to be redistributed. We need to cut back on ineffective, unproven procedures, unnecessary tests and over-priced cutting edge devices and drugs that are no better than the older products they have replaced. Some of those squandered dollars could be used to bring the uninsured into what Pelosi describes as “the loop.”

Pelosi ended her speech as she began it, talking about inequality. “People in the minority community receive the worst care,” she observed.  (For evidence, see Niko’s post on “medical apartheid.") “We must have community health centers,” Pelosi declared, “committed to providing high quality care.  In Washington,” she added, “there is a tendency to say, we’ve supported the community health center. So we have done what we need to do.  But we need to do much more. We need loan forgiveness for doctors who will practice in these communities. We need to promote healthy lifestyle, stressing exercise and nutrition.  And we need to create incentives for the public to participate in the health care system before they get sick.

“We can accomplish anything we set out to do,” she added. “It’s just a matter of making decisions about funding. A new focus on prevention through Medicare should be a very important part of what we do,” Pelosi added. Indeed, too often Medicare fails to cover preventive care (like regular eye exams for seniors who don’t suffer from eye disease) while covering exotic, unproven procedures.

Pelosi made another good suggestion: Across the country, “American schools could be places where children could obtain better health, nutrition, and exercise.” I agree. Schools in the inner cities need to offer breakfasts and lunches that are both healthy and appealing.  They need gymnasiums and playgrounds.

“Another very important part of this,” Pelosi continued, “Is that illness of the brain must be treated just like illness in any other part of the body. I hope to have legislation on the floor in a few weeks. Mental health disorders and addictions must be given the treatment they need.”  Here, she stressed just how much these disorders cost the nation in terms of lost days at work. Mental illness and addictions “lead to more lost productivity than cancer, heart attacks, strokes and arthritis combined. This is even more important now with all of our vets returning from Iraq,” Pelosi added.

Finally, she compared the cost of healthcare reform to the cost of the war in Iraq: “For the cost of 40 days in Iraq we could insure 10 million children in America.”

What does Iraq have to do with healthcare? The answer is that, in a world of finite resources, we have to make decisions about how to spend our wealth.

Comments

[maggie mahar]

Howard --
I agreee. The government's priorities are upside down.

[Howard C. Berkowitz]

Somehow, it seems characteristic of the policy debate that one has to buy the IOM report. I understand that there is a legitimate controversy for publishing government-funded research in expensive, hard to obtain peer-reviewed journals, because the subscription income pays for the costs of the review process.

I cannot, however, rationalize why the IOM/NAS would have a model where its operating costs need to be paid from publication sales. If the federal budget can't stretch to cover this kind of critical policy discussion, and it all comes out of a hypothetical grants budget, then I'm afraid I'd let the grantees of the NEA and NEH and perhaps PBS need to do their own fundraising.

This isn't unique to IOM, although NAS/NAE reports in, for example, military research can be read online, but in a painful page-at-a-time mode that clearly encourages paid downloads.

[Dr. Rick Lippin]

Thxs Maggie- for reporting on Pelosi remarks.

You are correct to state we cannot afford to supply the "best care" to everyone.

But this is the uninformed liberal myth that keeps getting perpetrated by many well meaning politicians from the left like Pelosi.

Even Michael Moore needs to get the message that prevention and rationing (oops- I said the "R" word) are imperatives. Both,of course, must be implemented with compassion.

Thanks again,

Dr. Rick Lippin
http://medicalcrises.blogspot.com

[maggie mahar]

Don & Ann--

Thank you both for your comments.

Ann-- One thing I learned here is that we all need to keep repeating and explaining what is wrong with our system, why more care is not better, how much waste there is, how if we wring out that waste, we have plenty of money to provide high quality care to everyone.

Paul Begala spoke yesterday at this conference and and, among other things, he talked about the failure of the Clinton healthcare proposal in the early 1990s (He was very invovled in that effort)

Begalia said that he realzed, in retrospect, that they hadn't explained the key points of the Clinton plan often enough or well enough.

Various publications, including the NYT did one story explaining the outlines of the plan, and then moved on , looking for "new" news. (ie. what the critics are saying)

Meanwhile, lobbyists spread misinformation about the Clintons' plan.

Health care and health care reform is a complex issue and for the public to understand it, you have to say the same thing over and over again.

I sometimes sound like a broken record talking about how $1 out of $3 of our healthcare dollars are wasted on innecessary tests, ineffective often unproven procedures etc.

But the fact is, this is news to most Americans, and you need to explain it over and over--and provide evidence and examples five different ways to people to begin to understand.

The notion that more care isn't necessarily better care, and that the newest, most expensive treatments often are not the best is
counter-intuitive. But it's true. And eventually, people will get it.
They'll connect it to something that happened to one of their friends or relatives.

Paul said he thought the media would do the job of explaining. But they won't. Limited space, limited energy and lack of interest in anything that isn't "newsy" enough to sell papers.

Don-- I agree, everyone should read the iom report-thanks much for sending the link.

[Ann Malone, RN]

Sorry that my above link doesn't work due to the ")" in it.
The correct link is http://www.defendhealth.org

Don - Good timing for the new IOM report; thanks

[Ann Malone, RN]

Yes!! From Maggie's synopsis it does indeed sound like Speaker Pelosi's speech was right on target. She covered an impressive range of the particular issues that need reforming, as well as conveying the deep and urgent moral responsibility that we ALL share to get these reforms underway AND accomplished. Thaks for blogging the speech, Maggie. I hope Families USA will put a video version online.

Can we each do something to help build the needed momentum for bold reforms, momentum that must take off in "Full speed ahead" mode after election day next November?

Will you share your ideas here - what are some of the things you're doing to build on this momentum for far-reaching reform?

A bit of what I'm doing is sharing this info with the nursing students I teach and with the listserve of health professionals and the public that I manage for the Alliance to Defend Health Care (feel free to sign up for it at http://www.defendhealth.org).

[Don McCanne]

The Institute of Medicine's report, "Knowing What Works in Health Care: A Roadmap for the Nation," addresses this very issue. Not only is the report a must read, it is also a plan for much needed action. It is available on the Institute of Medicine's website at http://www.iom.edu/CMS/3809/34261/50718.aspx