Millions of Americans suffer every day because we sidelined one word from our health reform debates: equity.
They endure health systems that treat them as second-class patients. They undergo partial procedures because it is all they can afford. They seek emergent treatment years after preventive therapies were indicated. They die waiting for undelivered care.
The public debate around the American Health Care Act (AHCA) is the latest reminder that health care is, well, complicated. Care is delivered by many practitioners. Costs march inexorably upward. Change one part of the system, and it affects many other parts of our fragmented, but interrelated, health care networks. Yet health care might be less complicated if we returned that missing word to the center of our debate.
Forty-five years ago—in March 1972—the Scottish physician Archie Cochrane delivered a lecture that still shapes our health care debates. In discussing how a physician should select a treatment for a patient, he concluded that a physician should administer treatments whose efficacy had been demonstrated through a randomized controlled trial. He called this kind of trial a "very beautiful technique," in which research subjects were randomly assigned to various treatments as a way to minimize bias.
Since Cochrane's lecture, the adoption of randomized controlled trials eventually forced physicians to reconsider which treatments truly worked and at which cost they were worth administering. His lecture (and the short book that resulted from it) was entitled Effectiveness and Efficiency, and the two words became the lodestars of US health care, as we subsequently measured treatments by their outcomes and their costs. Cochrane's lecture led directly to the ascent of evidence-based medicine and indirectly to legislation such as the Affordable Care Act (ACA). Medicine was reformed around the pursuit of efficient and effective outcomes in value-based models.
Yet, according to his autobiography, One Man's Medicine, Cochrane later regretted that the lecture's title left out a third essential word: equity. Like many a writer, he could not have imagined all the future uses of his text. He delivered "Effectiveness and Efficiency" to a British audience in the context of their National Health Service, one of the United Kingdom's publicly funded health systems. Then, and now, the various National Health Services provide comprehensive, free health services to all UK citizens, and Cochrane was discussing which treatments they should deliver. In the lecture, he told his audience that his own slogan was "All effective treatment must be free." With that kind of slogan, in a country where health care is widely regarded as a public good, equity can be assumed.
In the United States, on the other hand, health care is sometimes a public good you receive as a citizen, as in emergency medicine services, but is more commonly regarded as an economic good, a product or service you choose as a consumer. In the United States, equity can never be assumed, and pursuing effectiveness and efficiency dominate the debate.
For all its limitations, the ACA shifted US health care toward equity. It could have more accurately been called the Accessible Care Act, as the legislation's chief virtue was the expansion of Medicaid to millions of Americans who previously did not qualify for health insurance, mostly the working poor. As a physician at Denver Health, an academic safety-net hospital in Colorado, I saw the lives of the patients I met rapidly transformed when health care became more of a public good. Before the ACA, the majority of our patients were uninsured. After the ACA, the majority were on Medicaid. We could now deliver first-class care, administer indicated procedures, and provide preventative care.
Through the efforts of institutions such as my own, health outcomes improved in Colorado. A recent analysis by the Commonwealth Fund ranked Colorado's health care system sixth in the nation, up from a baseline ranking of eleventh. The report's authors observed that Colorado's health care system became effective at delivering quality care and efficient at administering less costly treatments through the expansion of Medicaid. Once we restored a measure of equity to our system, our effectiveness and efficiency improved. We were not alone—all the top-ranked states in the report accepted the Medicaid expansion.
Under the American Health Care Act, equity would once again have gone missing in Colorado. According to an analysis by the Colorado Health Institute, 600,000 Coloradans (or one out of every nine current residents) would lose Medicaid by 2030. That decline mirrors the numbers from the Congressional Budget Office report, which estimates that access would decline nationwide, with 14 million more Americans uninsured by next year and 24 million uninsured by 2026. As the health reform debate continues in Congress this week, we must continue our pursuit of equity in health.
If equity goes missing from the conversation again, many of my patients will go missing as well. The AHCA proposed jettisoning the ACA's requirement that Medicaid cover mental health and addiction services as essential health benefits. In my clinical specialty of psychiatry, that means most of my patients would return to the jails and shelters where persons with chronic mental illness end up when they aren't receiving the health care they need.
As a fellow physician and writer, I share Cochrane's regret about the missing word in his title. If he had included it, perhaps our debates would begin by asking how we can build equity-based medicine instead of just effective and efficient medicine.
Author's Note
Abraham Nussbaum is a full-time employee of Denver Health. He receives royalties from books published by American Psychiatric Association and the Yale University Press.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/2pOMTXQ
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