The steady deterioration of health insurance coverage.

Today’s price tag for obesity is $76 billion in direct costs and $117 billion in indirect expenses. By 2012 it is estimated that 40% of Americans will be obese. We have allowed this epidemic to sneak up and overtake us. In ten year’s time, we will undoubtedly regret not giving more attention to the obesity epidemic by fully recognizing and addressing its impact on our health care system and its relationship to chronic disease.

Obesity is associated with an extensive list of co-morbid conditions, including type 2 diabetes, heart disease and certain types of cancer. But it also has been linked to a litany of other chronic diseases including (but not limited to): asthma, depression, sleep apnea, gout and osteoarthritis. Individually, each of these conditions can create a significant compromise in quality of life and productivity. Together, they constitute an overwhelming human and financial toll – not just for individuals and their families and caretakers, but also for employers, who struggle to accommodate their employees’ insurance needs, while facing reduced productivity and increased absenteeism. And, of course, the impact extends to the U.S. healthcare system in general.

Whether we are addressing childhood or adult obesity, we must also recognize that prevention is only half the battle. If we are to make significant progress against this public health crisis, treatment must be a significant part of the discussion. That includes securing better coverage for the breadth of weight loss intervention methods that obese individuals may require; implementing a broadened research agenda on effective interventions that address both obesity and related chronic disease; and finally, measuring our weight loss efforts against health outcomes, rather than against stigmatizing and unrealistic aesthetic standards.

At a time when the economy is in crisis and health reform is a top priority, obesity must be on the agenda. When we look back, it may become all too clear that our failure to adequately address adult and childhood obesity was the defining moment in our failure to reduce the growth of health care costs and improve health outcomes.

We are making three very, very big mistakes:

1. Believing that we can control health care costs without having anyone choose between health care and other uses of money.

2. Believing that we can improve quality without having providers compete for patients based on quality.

3. Believing that we can improve access by inducing people to drop their private coverage and join public plans that pay providers below market rates.

I think one great regret we may have a decade hence is our not being more respectful of Jack Wennberg's and his research associates' work at Dartmouth University.

I do not know what more health services researchers can do to alert policymakers to a glaring flaw in our health system. Yet the Dartmouth research findings have been studiously disregarded by policymakers for over two decades.

To be blunt, I am quite tired of hearing Americans wring their hands over the alleged Baby Boom Tsunami and over the "entitlements crisis" we are said to have.

But what are the proposed solution to this "entitlements crisis"? What is actually meant by the words: "the imperative to restructure [or reform] Medicare"? Having privately owned health savings accounts for retirement managed by Bear Stearns? Rationing health care to the elderly? Paying 14% more than for traditional Medicare to privatize Medicare's purchasing function, as we now do under Medicare Advantage? Or inquiring why it is necessary to spend so much more on medicare beneficiaries in some parts of the country than in others?

Some of us -- Bob Reischauer included, as I recall -- were talking over 10 years ago about tackling the Wennberg Variations -- perhaps through regional rather than national budgeting. But the idea never caught on. It was always viewed on the Hill as too delicate a topic.

It remains to be seen if brother Orzsag has enough clout to make Wennberg's research count in the White House. At least we know from his CBO reports that he is keenly aware of the issue.

By the way, in re Secretary Leavitt's video presentation, I would remind him that interest on the federal debt IS an entitlement, too.

Uwe R.

Long term care is an important health care issue that is seldom mentioned. What most consumers and even many policymakers do not realize is that Medicare coverage for long term care services is extremely limited, leaving huge gaps in the types of services most elderly and disabled Americans need.

The absence of any national strategy has thrust the responsibility to the states and to the Medicaid program in particular. In turn, Medicaid now serves as the de facto long term system of care, spending more than $118 billion to provide services to more than three million individuals. This also means our current system forces consumers to impoverish themselves in order to receive Medicaid long term care services. While there have been several promising developments in recent years, including expansion of Medicaid home and community based services initiatives, the creation of the Money Follows the Person grants, and support for expanding the Long Term Care Partnership program, these program are not sufficient to meet the growth in demand for services by the increasingly aged population.

As Congress and the Administration push forward with health reform, they would be remiss not to include a national strategy with respect to financing of long term care services for the elderly and people with disabilities. Medicaid cannot carry this burden alone. Other sources of coverage, whether federal, personal, familial or community-based must be developed and some uniformity and standards for the long term care insurance products already in the marketplace could be developed. In addition policymakers should look to the states’ experiences in working with this population as well as the lessons from Medicare Part D implementation to learn how best to educate and gain the trust of the target population.

These types of efforts would free resources to help make Medicaid financially sustainable and allow states to focus more attention the core functions of the program.

Few health policy mistakes have been made by the new Administration and Congress thus far. President Obama and Congress seized their early opportunities to lay the groundwork for more fundamental change with their reauthorization of the Children’s Health Insurance Program (CHIP) and the passage of the American Recovery and Reinvestment Act with health provisions to invest in information technology and comparative effectiveness research. And President Obama's 2010 budget, which set aside $634 billion for health reform over 10 years, demonstrates his commitment to passing health reform legislation this year.

President Obama has framed the health care overhaul as an integral part of economic recovery—and emphasized the need to improve quality while maximizing efficiency and expanding coverage. It is imperative that President Obama and the 111th Congress maintain this momentum. The Commonwealth Fund's Commission on a High Performance Health System has issued a report with policy recommendations addressing insurance coverage, payment reform, and quality improvement that shows such policies, if enacted now, could slow health spending growth by $3 trillion by 2020.

My greatest concern is that the solution will be based on the popular myths of 2009.
Myth 1: The uninsured are flooding emergency rooms. In JAMA Oct 29 there was an analysis of 127 articles about the uninsured and emergency rooms that concluded that the uninsured are not disproportionately represented in the emergency room. Moreover, the number of insured persons who are showing up in emergency rooms is increasing.
Myth 2: Obesity can be reduced by nutritional information and willpower. It is very likely that obesity is a sign that an individual’s endocrine system is not working well. Science has made advances in the understanding of our endocrine system, the role of hormones, the functions of the different types of fat cells work, and the genetic variations that make people metabolize food at different rates. These data help to explain the correlation between obesity and diabetes and why children who are obese end up as adults with health problems.
Myth 3: The empowered consumer. Discussions of consumer empowerment become meaningless unless we acknowledge and address the range of consumer knowledge and the ability as well as desire to make decisions.
Myth 4: Underserved communities live shorter lives. Hispanics are the group least likely to have a regular source of care or to be insured but live longer than non-Hispanic whites.
Myth 5: Focus on old models of disease. We need to include in our solutions the causal relationship (triggers) of compromised air and water on diseases, e.g., cancer and heart disease.

Although it far too early to tell, my candidate for likely most serious mistake or missed opportunity for 2009 will be inadequate standards-setting and other decisions to ensure true interoperability between certified EMR systems. Health IT is potentially a great enabler for comparative effectiveness analyses, clinical decision-support systems and many other strategies that could improve the inefficiencies in our current health care environment. The stimulus bill contains $2 billion for HHS to be used to for grants and loans to encourage the development of EMRs and $17 bill for Medicare to use for incentive payments to institutions and physicians. However, much of this spending will be meaningless unless it is preceded by the necessary standard-setting decisions.

Given the difficulties that surrounded the development of HIPAA standards during the late 1990’s and the tortuous history that the Department of Defense and the Veterans Administration have experienced attempting to make their two systems interoperable, it is urgent we reach consensus on standards and interoperability designs before embarking on a $19 billion spending spree but I am not at all confident that this will happen. If this does not happen, the $19 billion will represent a missed opportunity of significant portion and potentially, a great waste of spending.