COMMENTARY : It’s Time to Get Serious About Curing the Health System’s Ills

Despite repeated calls for action, the serious deterioration in our health system continues unabated.

The California Legislature recently adjourned from an otherwise productive session without achieving progress on this issue. The Board of Supervisors was forced to slash the Indigent Medical Services budget by an incredible 54%. The Medi-Cal network has essentially disintegrated with the decision by Fountain Valley Regional Hospital and Medical Center to withdraw from the program and the appearance that another major hospital is ready to do so. Worst of all, there seems to be no major consensus solution on the horizon.

This situation has severely restricted access to needed health services for millions of Californians. Many people have been forced to seek routine care in already overloaded and underfunded emergency departments, the only guaranteed access point to our health system.

A study of 1,000 UCI Medical Center emergency patients found that 25% regularly use the emergency department for their basic health needs. This phenomenon has led to overcrowding, trauma center closures, ambulance diversions and hospitals choosing to downgrade or eliminate emergency services. This affects all citizens, rich and poor, who may be less able to get timely emergency care.

While the United States spends nearly 12% of its gross national product on health care, by far the most of any nation, we rank just 20th in infant mortality, and our life expectancy is only average. There are a host of factors that explain this apparent paradox. In a study of emergency admissions at UCI, we found that patients with restricted access who delayed in seeking care had a 25% longer and more expensive hospital stay.

Inadequate public discussion of ethics and resource allocation has led to high societal and legal expectations of unlimited care as a basic right. This has forced physicians to practice defensive medicine by ordering unnecessary tests and procedures, costing about $50 billion to 100 billion annually. Because of the immense complexity of insurance forms and regulatory oversight mechanisms, the United States leads the world in administrative spending, with more than 20% of total costs. We have made no serious attempts at comprehensive planning, public education or prevention of illness. California spends $18 billion each year for health and societal costs related to alcohol and tobacco abuse.

Despite the scope and magnitude of the health care crisis, and the plethora of reform recommendations from many panels and commissions, the legislative solution remains elusive. The reasons include lack of consensus among the major players, lack of political will to make difficult decisions and lack of political pressure from voters.

Any comprehensive plan must involve the following:

1) Health insurance. Everyone, including the poor and “uninsurable,” must have some form of insurance providing access to basic services and long-term care. This system should be primarily based on employers, with cost tied to personal income. Insurance plans must be more standardized and simplified and cannot be left solely to market forces.

2) Tort reform. Reasonable standards of care with a clear medical-legal linkage must be developed. Removing this problem from the courts and instituting some form of binding arbitration would be in the best interests of everyone and would save billions yearly in defensive medicine costs. By removing “blame” from the system, all patients who are injured or suffer an unavoidable bad outcome could be quickly and fairly compensated.

3) Emphasis on prevention/wellness. We need to establish financial incentives for wellness, such as tax credits or insurance rebates. Our system often makes it difficult to receive screening exams, immunizations and prenatal care, while we routinely incur enormous spending in covering intensive care and high-technology, in-hospital services.

In lieu of the big-fix solution, immediate stabilizing measures are required. Late last year, the Orange County Emergency Medical Care Committee unanimously passed a cost-effective, seven-point, short-term plan in anticipation of the evolving crisis. It calls for using tobacco tax money; supporting mandatory motorcycle helmet legislation; supporting stiff penalties for drunk drivers and implementing all available cost recovery mechanisms for alcohol-related injuries; developing a high-profile education campaign stressing disease prevention; supporting a requirement for state-mandated auto insurance to include a basic health package; creating a disaster mode in which good-faith providers who serve the uninsured could be deputized to limit liability, and developing an emergency prioritization list for county Indigent Medical Services money.

The November election represents a golden opportunity for voters to authorize needed resources. Proposition 134, the nickel-a-drink alcohol tax initiative, would raise more than $730 million annually for law enforcement, mental health, public education, alcohol treatment centers, emergency and trauma care and battered women shelters. A broad coalition supports the initiative.

California has the lowest overall alcohol tax in the nation. The wine tax was last raised in 1937, the beer tax in 1959 and the spirits tax in 1967. The annual revenue of $129 million from these taxes offsets just 1% of the total societal cost of alcohol abuse, with taxpayers subsidizing 99%. As 11% of the population consumes 68% of the alcohol, Proposition 134 is an initiative that all of us can support.

The view from the front line is not a pretty sight. Our health safety net is full of gaping holes large enough for any of us to fall through. Your constructive participation in the political process could make the difference in saving lives.