As the national debate over health care reform rages, we’re asking Schweitzer Fellows and Fellows for Life — who are working directly with the populations whose needs are unmet under our current health care system — to weigh in.
Today, we talk with 1993-94 Boston Schweitzer Fellow Rushika Fernandopulle, M.D., M.P.P. As a Boston Fellow, Rushika collaborated with The Alliance for the Homeless, where he visited shelter clinics and assisted clinicians. He created an orientation manual for volunteers working with shelters on soliciting donations, liability issues, and health care.
Fernandopulle earned his degrees from Harvard University, is board certified in internal medicine, and serves on the faculty of Harvard Medical School and as an attending physician at MGH. He was the first Executive Director of the Harvard Interfaculty Program for Health Systems Improvement, an effort to leverage top faculty from across Harvard University and senior leaders in health care organizations to tackle the largest, most difficult problems facing the health system. As part of this role he was involved in research on many aspects of the U.S. health care system including racial disparities in care, clinical information systems, pay for performance, and the uninsured.
He is currently an executive at Renaissance Health, an organization that works to improve the quality of healthcare delivered to patients.
Read on for Part 1 of his thoughts on health care reform, and check back tomorrow for Part 2:
Once again health reform is in the air in Washington, and hopes run high that perhaps this will be the time that real change happens. There is much agreement on three basic problems:
1.) The 50 million-plus Americans who lack insurance coverage;
2.) Costs that are much higher than the rest of the world’s, and that are rising inexorably faster than inflation and wages;
3.) Serious concerns about quality, both in terms of experience as well as outcomes, despite such a high price tag.
As a practicing physician and Schweitzer Fellow for Life who has spent much of his time trying to build radically new care delivery models, especially for the poor and vulnerable, however, I am concerned about the current discussion about solutions.
Much of the focus is on providing insurance coverage to the uninsured, through regulations on the insurance market, mandates on employers +/- consumers, and the potential creation of a public insurance alternative. While these steps will almost certainly in the short run reduce the number of uninsured (as they have in states like Massachusetts which have tried them), I fear they miss several fundamental issues which in the long run will undermine their success.
The first issue is the single-minded focus on providing insurance coverage. When you ask the uninsured what they want, most do not answer “insurance”; instead they say they want “care”– for instance, to see a doctor when their child has an ear infection, or to get their own diabetes diagnosed and treated.
The reality is that there are a host of barriers to getting care even for those with insurance. In many parts of the country, particularly poorer ones, there aren’t providers to see, or else none who take insurance payments. Many doctors’ offices do not provide translation services, or are hard to get to without a car. Many working people do not have sick time, so going to a doctor during regular office hours (the only time the vast majority are open) requires missing work — at best losing pay, at worst getting fired. Giving people insurance without addressing these other access issues misses a key part of the problem.
A second issue is addressing the root cause of the high number of uninsured — the high (and rising) cost of health care. We pay almost twice as much per person for health care than virtually every other country in the world, with many poorer outcomes.
The core reason so many people are uninsured is because they (and/or their employers) cannot afford the premiums. Indeed the cost of a family policy in some states now exceeds the income from working a minimum wage job — so if you paid every cent of every paycheck earned at minimum wage, you still couldn’t afford a family insurance policy, let alone have any left over for rent, food, heat, or other expenses.
Every time the cost of providing health care nudges up, more people go off the insurance rolls. What Massachusetts is finding out is that unless we address the root causes of high and rising health care costs, any fix is unsustainable and will eventually break the bank and be dismantled.