OPINION:
National comprehensive health care and health care insurance reform are needed both to improve quality and to decrease rising insurance costs. The Affordable Care Act (ACA) failed these goals because it lacked five interrelated foundational requirements for success: adequate quality health insurance choice, improved drug safety and competitive drug costs, fostering of health literacy, full realization of electronic health record (EHR) and IT potential and correcting the problems of behavioral health delivery.
Limited health insurance choice causes high costs for families and employers, causing increases in the number of uninsured and underinsured patients. Options other than large insurers with large profit margins are needed to lower overhead and give more control to the consumer. “Association” health plans could provide alternative accounts to small businesses, sole proprietors, the self-employed and individuals. We could also increase the number of consumer operated and oriented plans (CO-OPs) in the entire country and ensure universal access to membership. Offering insurance terms longer than one year would incentivize insurers to promote preventive care and to consider long-term effects of benefit denials. Finally, Medicaid needs reform as it offers little choice, its administration by private insurers threatens access to care, and loopholes in state payment schemes create inefficiency and inflate cost.
President Donald Trump has successfully lowered many drug prices, but we should legislate permanent drug and medical device price negotiations for all health insurance plans that are funded in any manner by the federal government so that future presidential administrations do not reverse these gains. “Big Pharma” has argued fallaciously that such reduction would lead to less research and innovation, but other countries could be asked to pay more and thus maintain some, if not all, of any given drug’s profitability. Furthermore, drug companies would be incentivized to increase efficiency and innovation. The scrutiny of pharmacy benefit managers (PBM) must continue, including transparency of drug “rebates” and allowing patients to reap the gains of PBM negotiations. For enhanced drug safety, we must rein in the wild west show of snake oil salesmen plaguing our over-the-counter medicines and supplement industry.
Higher health literacy correlates with better outcomes. Patient engagement with providers and the management of all aspects of one’s own health care depend on health literacy. In turn, power mismatches in both patient/physician and patient/health system relationships are lessened, fostering better resource use. Inadequate health literacy costs up to half a trillion dollars per year but is relatively cheap to improve especially with social media. Improving health literacy perhaps offers the best return on investment. Health literacy includes understanding smart food choices, and further work in this space is sorely needed such as what is being done as part of the Make America Healthy Again (MAHA) movement. Studies have shown dietary education in elementary school children improves both their food choices and their families’ choices. More states should limit the use of SNAP and child nutrition money on sugary soft drinks and junk food, which account for over 10% of SNAP spending. The benefits of reducing youth overweight and obesity cannot be overstated.
IT needs to encompass communication and data mining. We should improve interoperability of electric health records (EHR), use social media and digital messaging to enhance health maintenance, screening and literacy and smooth communication among all those involved in patient care delivery. EHRs contain enormous amounts of data that should be used to conduct virtual clinical trials and comparative effectiveness research, develop better quality metrics and screening tools, improve diagnostic accuracy and increase the yield of public health research. For example, minors could be screened for risk of behavioral health disorders and linked dietary vulnerabilities, allowing for crucial earlier intervention.
Finally, behavioral health is likely the area that needs the most work and contains the most potential for increasing value. Problems include a critical lack of access to health care practitioners, insufficient inpatient psychiatry beds, inadequate payment for hospital admissions and practitioner care, poor regional behavioral health coordination and weak patient referral and treatment algorithms. The result is increased homelessness, rising suicide rates, behavioral health problems in our youth and unnecessary and counterproductive incarceration of the mentally ill. Opioid overdose and opioid use disorder alone cost an estimated $1 trillion annually, and the cost of other untreated mental health disease is another $500 billion. We must both grow and improve the efficiency of the behavioral health workforce and increase treatment capacity. As a nation, we are at least 36,000 inpatient beds short of the minimum required for adequate coverage. Building 50 to 100 large behavioral health treatment complexes containing the full range of inpatient and outpatient services would bring together local communities, create needed research centers and help alleviate our mental health crisis.
As physicians, we feel reforming and improving health and health care can be the unifying force so badly needed in our country.
• Rep. Andy Harris has represented Maryland’s First Congressional District since 2011. An anesthesiologist and veteran who served in the U.S. Navy Medical Corps, he chairs the Agriculture, Rural Development, Food and Drug Administration, and Related Agencies subcommittee of the House Appropriations Committee. Dr. Renee Desmarais has practiced cardiology for the past 33 years in Salisbury. He is president of the Wicomico County Medical Society and on the Board of Trustees of MedChi, the Maryland State Medical Society.
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