Turn health care on its head, panelists say

Lack of primary care and attention to chronic disease are the real ills of the health care system, panelists said at a seminar on health care reform for California Broadcast Fellows.

Anthony Iton, public health officer for Alameda County, says that 3 out of every 4 health care dollars goes to the treatment of chronic disease. "It is the elephant in the room. If you're not talking about chronic disease, you're not talking about health," he says.

While the "heroic care" of intesive care units and emergency rooms are the sexier stories, preventive care is the more effective and cheaper option for longer and healthier lives. 89% of money spent in health care happens at what Iton calls tertiary institutions, which focus on the 50 and older population. But it is in the 20s and 30s where prevention can have the greatest impact. This is when people decide to smoke and drink and not exercise, says Iton.

But the system of incentives on all sides -- private insurance, Medicare and Medical, medical schools -- focuses on emergency care, end of life care and death. Julie Rovner, a National Public Radio correspondent on the Health Policy and Science Desk, says, "The incentives are so screwed up at every level. Journalists have bad incentives too, to cover where the fighting is."

The Finance Committee is the most out-in-the-open in its deliberations on health care delivery system reform. Theirs is the most important piece of legislation that creates incentives to deal with chronic care, says Rovner.

Panel moderator Michelle Levander, director of the California Endowment Health Journalism Fellowships, says that it is easy for journalists to lose the real stories in the midst of political wrangling and big numbers. According to data collected by the UCLA Center for Health Policy Research, 6.5 million nonelderly Californians, nearly 20% of the nonelderly population, were uninsured in 2005. Here in Southern California, there are 57,000 people uninsured between the Los Angeles International Airport and Mulholland. Compare that to Vermont, where there are 50,000 people uninsured in the entire state, and the figures can be staggering.

Rovner explains the politics of health care reform; the committee leaders in the House and Senate are key players but they often have conflicting interests. Health care overhaul has an estimated price tag of $1.5 trillion over 10 years, and the question of who will foot the bill is a contentious one. One suggestion has been to create a sin tax on sugary soft drinks, which sounds well and good, says Rovner, until you consider that soft drinks are not actually made with sugar. They are sweetened with high fructose corn syrup; corn is made in Iowa, and the ranking Republican on the Senate Finance Committee is Iowa Sen. Charles Grassley. (For more analysis, see Rovner's May 22 piece, Health Care Overhaul Efforts Inch Along.)

The seminar looked to the largest free clinic in the country to understand the effects of a health care system focused on emergency care. Venice Family Clinic on the west side of Los Angeles County serves 23,000 patients a year at seven locations. Elizabeth Benson Forer, the chief executive officer and executive director, says that community clinics, free clinics and community health centers serve people with low incomes, no health insurance and no access to care.

State initiatives to shore up budget deficits are hurting patient care, though. If current proposals are enacted, says Forer, $1 to $2 million of the Clinic's $20 million budget will be cut immediately. Coupled with reduced private funding, cutbacks and loss of services are inevitable. "Every patient we have will be impacted, their families will be impacted," Forer says. "The only thing we've been doing is bolstering our volunteers because that's the only way we can function with nothing."

Iton cautions that, "Health does not equal health care. Health insurance reform is not the same as health system reform." Even if he had enough money to pay for every person in Alameda County's doctor visits, the wait time for a new appointment for specialty care is 12 to18 weeks and the County is about 100 primary care providers short.

Social determinants to good health also drive life expectancy, not just access to health care, he says. Iton's office examined death certificates in Alameda County and mapped the geographical distribution of short, intermediate and long life expectancies. (See a PDF presentation of data in Alameda County on their website, as well as a report on health and social equity.) He found that there are "hotspots of premature death," a correlation bewteen poverty and low life expectancy. "Every additional $12,500 in household income buys one year of life expectancy."

"Death is not randomly distributed," Iton says. "You can predict how long someone will live if you have their address."