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
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
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
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
“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