Placing health reform in an historical context shows how the debate has evolved. For example, the National Bipartisan Commission on the Future of Medicare was formed to address Medicare’s projected insolvency – at a time when the overall focus for health reform was on cost containment. However, while the Commission met and deliberated, the booming economy shifted the debate away from cost containment towards access and coverage expansion, and the Commission’s 1999 final report, proposed adding an expensive outpatient drug benefit to Medicare.

Comparing two more recent perspectives on the future of the US healthcare system also illustrates how thinking about health reform evolves.

In June, 2003, (6 months before Congress passed the Medicare Modernization Act), I gave a presentation to the Presidents of the State Medical Associations about the future of the US health care system. My conclusions were:

1. We will continue to have a patchwork system of private and public delivery and financing
2. Innovations – primarily genetics/individualized medicine and information technology – will change how medicine is practiced
3. Budgetary pressures will be a prime driver of change
4. Individual empowerment will continue to increase the role patients play in their own healthcare
5. There will be growing emphasis on demonstrating actual clinical and economic outcomes as a prerequisite for payment or regulatory approval.
6. There are (were) three directions the US healthcare system can go:
   A. “Consumer Opportunity”
   B. “More Medicare”
   C. “Comprehensive Care Management”

I posited that “Comprehensive Care Management” was the most likely outcome, and that integrated care management organizations that would be responsibile for the cost and quality of a patient’s entire range of healthcare services would become more prevalent and be the best way to improve the healthcare system.

I recently had the opportunity to reflect on this presentation while listening to Dr. David Blumenthal (Director of the Institute of Health Policy at Massachusetts General Hospital) give brief keynote remarks about the future of US healthcare to a group of policy interested medical residents. His top-line comments about where the US healthcare system is heading in the next several decades were:

1. The economy is a key indicator of healthcare spending – countries with higher per capita GDP spend a higher percentage of their GDP on healthcare.
2. Technology is changing the nature of clinical medicine as well as patient-physician interactions and relationships. In the future, these relationships will likely be more collaborative.
3. The private insurance market will change over the coming decades, with movement away from the current employer-based model to more individual based insurance decisions.
4. Making changes in Federal laws and programs will be very different after the 2008 election, and changes in Congress may be more important than changes at the Presidential level
5. Globalization will affect medicine, with more international delivery of medical care.
6. Change is going to be more of a constant feature of healthcare. Success in the future will require being ready for change, embracing change, and managing change.
   

First, Dr. Blumenthal’s comments where much more coherent than mine. And second, although I disagree with his views on the eventual demise of the employer based insurance system, it is valuable to see how the health reform debate has evolved because of real-world changes over the last 5 years:

• The use of information technology by physicians in care delivery is no longer speculation
• Genomics-based diagnostics and therapies are now realities
• Safety and quality are much more prominent issues in the public debate
• Budgetary issue are still important, and the pendulum is in the process of swinging from how do we pay for universal coverage to how do we contain costs as part of an overall strategy for promoting economic growth.

There will continue to be lots of debate about health reform – particularly during this election year, and in the next Congress. I don’t think we’ll see the singular focus on health reform like we had in 1991-94, but it will certainly be a big topic for the President, the Congress and the Country, and as Dr. Blumenthal noted (and I wrote last month), the economy will be a major influence on public and private health reform discussions and actions.

What do you think will happen, and when?