Too Few Prescriptions

The National Leadership Commission on Health Care has issued its first statement, a comprehensive diagnosis of the problems that need solving if Americans are to be assured access to affordable quality health care. The nation already is spending almost 11% of its gross national product on health care--more than any other nation--yet, as the statement notes, there is diminishing access and “access problems are likely to worsen.”

To that diagnosis the commission has appended a promise to work over the next 18 months to “identify incentives and disincentives to better health care--and how to make it accessible and affordable to all.” That promise is a good thing because there have been too many diagnoses of the problems and too few prescriptions for cures.

The statement is a useful reminder that one in eight Americans at some point in the year lacks any health insurance--a number than has increased from 35 million to 37 million in just two years. And it is useful to remind the nation that Medicaid, intended to assure quality care for the poor, now covers less than half those living at or below the poverty level. Almost half of Medicaid’s resources have been diverted to providing long-term care for the aged because there is no other support of last resort for that group.

It is also useful to be reminded that health-care inflation, at a rate of 7.7% last year, still is running ahead of general inflation despite all efforts to contain costs. The growing supply of physicians is resulting in cost increases instead of decreases. The commission concluded that “changes in the organization, delivery and financing of care present the greatest potential for controlling costs,” but it is not clear whether the innovations, including expansion of health-maintenance organizations and preferred-provider organizations, “will reduce only unnecessary care--trim fat and not muscle,” the statement notes.

The commission does point out one area where there is no debate: the cost-effectiveness of prenatal care. “The Institute of Medicine maintains that every dollar spent on prenatal care saves $3.38 in medical-care expenses for very low birth weight infants,” the statement says. “Yet those dollars are still not available to all who need them.”

The narrowness of this initial statement is a disappointment. We must now wait 18 more months to receive recommendations on strategies. In that period the commission has scheduled six major workshops on critical areas of health care, including controversies over the effectiveness and appropriateness of some procedures now common in American medicine. And the commission will be conducting public hearings in a number of cities to broaden the base of information and ideas.

This methodical approach has the virtue of making it more likely that the final recommendations will be the right ones. The commission staff feels that these initial months of defining the problems have strengthened the ability of the 35 commission members to work together decisively in the months ahead. They have now agreed on goals that certainly would serve the national interest.