The prognosis for U.S. health care: the health care system in the United States can provide technologically advanced treatments, but it still struggles to cover the basics. An expert outlines how to ensure more citizens access to high-quality health care.

Health care in the United States is a major industry that touches everyone. But it is also a troubled one, with costs accounting for 16 percent of the nation's gross domestic product, according to the Centers for Medicare and Medicaid Services.

Costs of health care doubled between 1993 and 2004, recently increasing faster than either inflation or incomes. At the same time, according to the Agency for Healthcare Research and Quality, measurements of the quality of care show little improvement from year to year. In addition, other studies detail sometimes alarming disparities in care, a growing population of uninsured citizens, and a shrinking percentage of employers providing health coverage to U.S. workers.

To discuss the present and future state of health care, economist Paul Ginsburg talked with TRIAL Associate Editor Valerie Jablow. Ginsburg is the president of the nonpartisan Center for Studying Health System Change, in Washington, D.C. By conducting studies of the health care system, Ginsburg and the center's researchers identify trends to help policymakers understand health system change and to support them in their decision-making.

TRIAL: What do you consider the most important trends in U.S. health care over the last 5 or 10 years, and how have they affected access to, and quality of health care?

Ginsburg: One of the most important trends has been the retreat from restrictive models of managed care. This occurred at a time of a booming economy, tight labor markets, and high profitability for many employers. Employers told health plans that they wanted less restrictive managed care products, which meant employees enjoyed broader provider networks, reduced authorization requirements, and greater freedom to consult specialists without seeing a primary care physician first.

But this led to rising health care costs and then to so-called consumer-driven health care, where consumers are given financial incentives to use less care or to choose some providers over others.

TRIAL: What would those financial incentives be?

Ginsburg: For instance, a plan might require the consumer to pay a large annual deductible--say, $1,000--toward his or her health care costs before insurance benefits start coming.

TRIAL: Wouldn't consumers with a large deductible be less likely to go to a doctor?

Ginsburg: Absolutely. And this trend raises a number of questions: Are consumers making good decisions? Are they cutting back on the care that is most elective? Or are they making bad decisions and cutting back on care that they really should get?

We certainly don't know the answers, There have been a few studies on prescription drug use, and they're not very encouraging.

TRIAL: What do those studies say?

Ginsburg: They say evidence of reduction of drug use in response to financial incentives exists across the board--drug use for management of chronic disease as well as drug use that might have been discretionary.

Prescription drug use is probably where financial incentives have had the largest impact. Some of the incentives I mentioned earlier influence which drug the consumer uses, rather than whether the consumer fills the prescription at all.

For example, many consumers are given a financial incentive to use generic drugs, causing a person who needs a cholesterol-lowering drug to choose a generic statin rather than a brand name like Lipitor. In most cases, this is a desirable change.

TRIAL: What do you think of proposals that the United States adopt a universal health care system, like those in Canada and the United Kingdom?

Ginsburg: We call them single-payer systems. The U.S. version of a single-payer system would be the Medicare program applied to everybody. That makes it easier to understand.

TRIAL: Would a single-payer system work in the United States ?

Ginsburg: That's a good question. It certainly would reduce administrative costs. But our political system, with its openness to lobbying by special interests, is a problem for successfully implementing a single-payer system. It is likely in our political system that top managers of a single-payer government program would have less authority than many of their counterparts in other democracies.

You can see this in the Congress's influence on the Medicare program: There are a lot of administrative or regulatory decisions that are clearly within the authority of the Centers for Medicare and Medicaid Services (CMS), but the Congress intervenes in many, either through informal pressures or writing legislative provisions. It's not a new development, but one that has gotten more extensive over time.

So the real question is, would the agency that runs the program have the authority to make the tough decisions needed to keep costs under control? Very few people consider that politically feasible in the next 10 years. A lot of people in health policy have been looking at what Massachusetts enacted recently as the direction the United States might go if it were to take steps to expand coverage in the near term.

TRIAL: What did Massachusetts do?

Ginsburg: Massachusetts will be expanding coverage through a combination of an expansion of their Medicaid program, subsidies to individuals with somewhat higher incomes, and a mechanism to enable individuals and small employers to buy insurance more efficiently. And they've also mandated that individuals be covered, offering subsidies to people with incomes below 300 percent of the poverty line to help make the coverage affordable to them. Employers are not required to provide coverage to workers, but those that do not will be assessed a fee.

The combination of expanding public coverage and providing subsidies to lower-income people to buy private coverage made for a key political compromise. But mandating that individuals be covered is critical to getting a major expansion of coverage, given the resources that the state has available.

If we see a significant expansion of coverage--either in individual states or as a nation--in the next 10 years, it will probably follow this model of piecing together a number of actions to expand private coverage.

TRIAL: How are we doing here with access to care--not just in terms of insurance, but also providing access to good doctors, good hospitals, and good equipment?

Ginsburg: That's hard to say. One thing we're seeing is increasing differences in access to care according to income. People with good health insurance have easy access to health care, unless they live in some rural areas. People without insurance have pretty bad access. People who have insurance through Medicaid, which is the public insurance program for low-income people, fall somewhere in the middle. For low-income people covered under plans that require substantial patient cost-sharing--say, a substantial deductible--I wonder: Will their access be significantly limited?

There is a racial gap in terms of access as well, and I think a large part of that is economic in its roots. Minorities are less likely to have health insurance and often live in areas where physicians and hospitals have far less in terms of resources.

The nation has been learning that our health care is of very uneven quality. Health care quality is a problem in other advanced countries, too. No one can say if it's better or worse here, but it's a lot worse here than you might think it should be. Scores of people die every day in the United States because of medical errors--you just don't hear about it because it's not big news in the way that an airplane crash that kills dozens of people would be.

TRIAL: Couldn't you say that, unlike flying a plane, practicing medicine is part science and part art, so there may be some gray areas?

Ginsburg: I don't want you to confuse art with errors. Traditionally, doctors have been at the top of the system, and no one ever questioned what they did. We are seeing a change in people's attitudes about accountability: Physicians and hospitals are becoming more accountable for the quality of their care. Medicare has taken the lead in providing incentives for hospitals to report measures of quality and publishing the data.

Our research shows that this step has motivated hospitals to focus more on quality in order to improve their scores. I do not know how many people are going to use this data to decide which hospital to go to, but hospitals are preparing for the possibility that this will come to pass.

TRIAL: How long have the problems of quality and access been with us ?

Ginsburg: The quality problems have possibly always been around, but may have grown worse as medical care has become more complex. The lack of a system to ensure quality may not have been as much of a problem when medical care was simpler--there was just less to go wrong.

The problem of access has also probably always been with us, but the measurement of disparities in terms of access is a relatively recent development.

TRIAL: What will hospitals be like in the next 20 years?

Ginsburg: The hospital outpatient department will continue to become an increasingly important part of the operation as advances in technology permit more care to be moved from the inpatient setting. One recent trend is hospitals facing competition for outpatient services from physician-owned facilities. Physician-owned surgery centers and offices are acquiring more specialty equipment to provide things like high-end imaging or gastrointestinal endoscopy procedures. Where the bulk of outpatient services will be provided in the future is uncertain.

TRIAL: What about the future of emergency rooms? It seems like much primary care for the uninsured or underinsured currently happens there.

Ginsburg: Well, certainly a higher proportion of the care of uninsured or underinsured patients is handled there. But much of the growth in the use of emergency rooms comes from greater use by insured people. One factor behind this is that physicians are less accessible to them after hours and even during regular hours. Physicians with tight appointment schedules are not that receptive to seeing emergency cases.

I think it's a real challenge for the health care system to accommodate people who don't have great access to regular physicians and whose medical problems are not emergencies. Currently, some large employers with a lot of people in a single location are developing primary care clinics at work. One of the effects they have is to save a lot of time for employees who are injured on the job.

TRIAL: If even insured people are using emergency rooms because doctors are over-scheduled or not accessible, doesn't that beg the question of whether there are enough doctors?

Ginsburg: Not necessarily. People will still be seeing a doctor in the emergency room--usually a specialist in emergency medicine. One factor behind the shift to emergency rooms is that physicians often do not have the technology that might be needed right away in their offices.

Take chest pains. Doctors today tell patients with chest pains to go to the emergency room because the best practice today is, after a cursory exam, to order an angiogram, and an emergency room is the only place you can get one right away. Standard courses of treatment are getting beyond what a physician's office can provide. That's something that has changed dramatically, and maybe for the better, because modern standards of treatment do get better results.

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