The following is a brief review of the reports released today by the Citizens’ Health Care Working Group, which is a group established by the federal government to study health care in the US, find out what citizens want to do to reform it, and make recommendations. Underlined text denotes quoted comments from the reports themselves.

You might read some media reports that say the group has been working for 3 years. False. It was called into creation—at some future point—as part of the Medicare Modernization Act—which is what created Part D—but the working group wasn’t formed until spring 2005. I applied—unsuccessfully—to be a member. It operated for about 18 months.

The group held numerous public meetings, conducted surveys, took written comments from the public and specified groups, e.g. corporations, unions, provider groups, etc. The report is to be presented to the President, who then “has 45 days to submit a report to Congress containing additional views and comments on the Recommendations, as well as recommendations for legislative and administrative action that the President deems appropriate. The statute also requires, no more than 45 days after receiving the President's report, five Congressional Committees to hold at least one hearing on the Final Recommendations and the President's report.”

The various reports—Executive Summary, Recommendations, the main report Dialogues with American People, and a preliminary report--are available at:

http://www.citizenshealthcare.gov/recommendations/finalrecs.php

Some of the reports themselves say that they’re “draft” versions, yet the Web site says that they’re final versions. They’re only available as pdf’s for now; html to come later.

There are 6 recommendations, with some specific actions recommended, but with a heavy does of generality. More on this below.

Commencing immediately, these recommendations will guide a five-year transition in American health care. The first set addresses serious threats to health security – very high costs and gaps in access to basic health care, preventive services, and health education at the community level. The second defines a package of core benefits and services, reflecting evidence-based practices and the principle of shared responsibility. The third builds a better health care system by achieving greater efficiency, improving quality, and restructuring end-of-life care.

Achieving Health Care that Works for All by 2012

Within these three sets, the Working Group recommends five multi-step actions for accomplishing its central goal stated in Recommendation 1, that “It Should Be Public Policy that All Americans Have Affordable Health Care" and that all Americans have access to a set of affordable and appropriate core health care services by the year 2012.

The 6 recommendations made

1. Establish Public Policy that All Americans Have Affordable
Health Care
2. Guarantee Financial Protection Against Very High Health Care Costs
3. Foster Innovative Integrated Community Health Networks
4. Define Core Benefits and Services for All Americans
5. Promote Efforts to Improve Quality of Care and Efficiency
6. Fundamentally Restructure the Way End-of-Life Services are Financed and Provided

My comments are general and based on an overview of the recommendations made and basic methods used. There’s much more to the report, but I want to offer some guidance at an abstract level on what it says and on how to interpret what it says while painting a picture with a very broad brush.

The major general findings didn’t require a massive study like this. They’re already known and easily verifiable by a basic survey of the public or are self-evident. For instance: Nearly 90% think there should be universal coverage. A high majority of those are willing to pay more in taxes to create a universal coverage system. These things are already well-documented, along with some other similar findings. Other findings are self-evident: People want a health system that’s “fair,” “cost effective” “high quality” “good service” etc. Everyone wants a “fair” system; the question is what constitutes “fair,” which the report does try to address, but not in-depth and not in any way that couldn’t have been addressed in a simple poll since these concerns aren’t anything new.

The least beneficial part of the study is perhaps the most important, unknown part—since it’s well-known that nearly all Americans support universal coverage—and that concerns financing. Along with many issues raised and recommendations made, the report hedges on what mechanisms to actually implement. Their insight into the main financing issue is this: It should either be done via a market-based model or a social insurance model, i.e, publicly-financed (aka a variation of single-payer). That is exactly the most salient and contentious issue in current health policy debate, and the report doesn’t make any real progress on resolving that central question. They offer only the most bare-bones outline of each model, which is sufficient as a summary since the general outlines are already well-know, so don’t look for any insight there. But the big question is what type of financing should be used, and there’s no recommendation regarding that. Everyone already knows that organizing the financing somewhere on the public-private continuum is the question; it’s the answer that needs to be addressed, which the report doesn’t address. Since there are numerous studied already out there which have collected and analyzed financing data, there’s no need for the superficial, non-original analysis done about it by this group.

In numerous other places where some reform is called for, the report refers to the need for a public/private partnership, which isn’t very illuminating and is descriptive rather than prescriptive. The report repeats the notion above of using either a “private” or a “public” model. Since the underlying issues have already been identified as in need of reform, the lack of specificity offers little advancement in terms of policy proposals, while perhaps offering some advance in recognition of the underlying concerns and wishes of the public.

One problem with the proposals that do have some element of specificity is that they’re spelled out mostly with respect to the existing system, that is, they aren’t offered in variations based on the over-arching system reform otherwise called for. Meaning that whatever tax reform they call for for some given issue, for instance, is framed in terms of the existing system and not spelled out for what it would look like under a publicly-financed system or other type of major reform, like a more-market based model. Since some of these taxes—sorry for being so general and abstract, but I don’t want to go back and drag us some details right now—would be/could be a moot point under a single-payer model—or otherwise very different—the recommendations aren’t so helpful. Making their recommendations in such a dynamic way, i.e. outlining that changing element A under system 1 will produce result X vs. changing it under system 2 will produce result Y, vs. changing it under system 3 producing result Z, would be extremely complicated, yet that’s what’s needed. The health system is so large and complex that changing one element will certainly have major ramifications elsewhere in the system, and the changes across over-all system types, e.g. single-payer vs. market-model, are enormous.

As difficult as it is, I think they should have offered a specific proposal of a publicly-financed model and then address the specific recommendation they make within that system in particular, and do likewise for perhaps a couple of broad market-based models and a full government-based system. The tinkering to be done within those broad system models could be spelled out more productively as a matter of policy analysis and recommendation. But they didn’t do that, and since they didn’t make me a member of the commission, they lost out on this little bit of insight. As is the case with these types of big “citizen’s commission on health care” (I think I have about 4 major such studies with the word “citizen” in the title somewhere around here) single-payer advocates aren’t included—usually, and I can’t think of any major, recent ones to the contrary. But enough self-pity.

All of these points from above aren’t to say the report is without merit, and in the details of it—which I haven’t pored over yet—there are surely some very good recommendations and/or new information to be shared. Some of those things in the report relate to the actual provision of care and the organization of provider relations, facilities, systemic issues, etc. And I have no competency in addressing those things. It would be great if some of the medical professionals here could offer their insights into those sorts of things.

The lack of specificity, and the questionable value of some of the specific recommendations since they don’t take into account the circumstances and hence ramifications of the changes under different overall systems, makes me think the report is less valuable than I expect will be claimed by many politicians and pundits. To say nothing of the press, who don’t have the time and expertise to really dig into these sorts of things. We’ll see.

I expect to report additional comments on the report after I’ve had time to really plow through it, so my comments are themselves, obviously, very general and non-specific.