Restoring fairness to the health law debate

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Millions of Americans suffer every day because we have left out one word from our health care reform debates: equity.

They endure health systems that treat them like second-class patients. They undergo partial procedures because that’s all they can afford. They are looking for an emerging treatment years after preventative therapies were indicated. They die while waiting for undelivered care.

The public debate around the American Health Care Act (AHCA) is the latest reminder that health care is, shall we say, complicated. Treatments are provided by many practitioners. Costs are rising inexorably. Change one part of the system, and it affects many other parts of our fragmented, yet interconnected, healthcare networks. Yet health care could be less complicated if we put this missing word back at the center of our debate.

Forty-five years ago, in March 1972, Scottish physician Archie Cochrane delivered a lecture that still shapes our debates about health care. In discussing how a physician should choose a treatment for a patient, he concluded that a physician should administer treatments that have been shown to be effective by a randomized controlled trial. He called this type of trial a “very nice technique”, in which research subjects were randomly assigned to various treatments to minimize bias.

Since the Cochrane conference, the adoption of randomized controlled trials has finally forced doctors to reconsider what treatments really work and at what cost they are worth administering. His lecture (and the resulting little book) was titled Efficiency and performance, and the two words have become big hits in US health care as we then measured treatments by their outcomes and costs. The Cochrane conference led directly to the rise of evidence-based medicine and indirectly to legislation such as the Affordable Care Act (ACA). Medicine has been reformed around the pursuit of efficient and effective outcomes in value-based models.

However, according to his autobiography, A man’s medicine, Cochrane would later regret that the title of the conference omitted a third essential word: fairness. Like many writers, he could not have imagined all the future uses of his text. He presented ‘Effectiveness and Efficiency’ to a UK audience as part of their National Health Service, one of the publicly funded healthcare systems in the UK. Then, and now, the various National Health Services provide free comprehensive health services to all British citizens, and Cochrane was discussing the treatments they should provide. At the conference, he told his audience that his own slogan was “All effective treatment must be free”. With this kind of slogan, in a country where health care is largely considered a public good, fairness can be assumed.

In the United States, by contrast, health care is sometimes a public good that you receive as a citizen, such as in emergency medicine services, but is more commonly viewed as an economic good, product, or service. that you choose as a consumer. In the United States, fairness can never be assumed, and the pursuit of effectiveness and efficiency dominates the debate.

For all its limitations, the ACA has moved American health care toward equity. It might have been more accurately called the Accessible Care Act, as the main virtue of the legislation was the extension of Medicaid to millions of Americans who were previously ineligible for health insurance, primarily the working poor. . As a doctor at Denver Health, a safety-net teaching hospital in Colorado, I saw the lives of the patients I met change rapidly as health care became more of a public good. Prior to the ACA, the majority of our patients were uninsured. After the ACA, the majority were on Medicaid. We could now provide first class care, administer indicated procedures and provide preventative care.

Thanks to the efforts of institutions like mine, health outcomes have improved in Colorado. A recent Commonwealth Fund analysis 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 has become efficient at delivering quality care and efficient at delivering less expensive treatments due to the expansion of Medicaid. Once we restored some fairness to our system, our effectiveness and efficiency improved. We weren’t alone — all of the top-ranking states in the report agreed to Medicaid expansion.

Under US health care law, fairness would once again be gone in Colorado. According to an analysis from the Colorado Health Institute600,000 Colorado residents (or one in nine current residents) would lose Medicaid by 2030. This drop mirrors figures from the Congressional Budget Office Reportwhich estimates that access would decline nationwide, with an additional 14 million Americans uninsured by next year and 24 million uninsured by 2026. As the health reform debate heats up continues in Congress this week, we must continue our pursuit of health equity.

If fairness disappears from the conversation again, many of my patients will also disappear. The AHCA has proposed dropping the ACA’s requirement that Medicaid cover mental health and addictions services as essential health benefits. In my clinical specialty of psychiatry, that means most of my patients would return to the prisons and shelters where people with chronic mental illness end up when they don’t get the health care they need.

As a fellow physician and writer, I share Cochrane’s regret over 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 effective and efficient medicine.

Author’s note

Abraham Nussbaum is a full-time employee of Denver Health. He receives royalties from books published by the American Psychiatric Association and Yale University Press.

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