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Opinion Column

Reading the Fine Print on Health Reform: Encouraging News For Public Health

Partisan health reform fights have focused on a handful of concerns: the proposed public health insurance plan, individual and employer mandates, financing measures to subsidize low-income Americans and to cover the uninsured. As a combatant in some of these fights, I’m not one to say the partisan conflict is misplaced.

Still, it’s unfortunate that there is so little oxygen left for other concerns. I’ve been reading the mammoth draft recently released by Senator Edward Kennedy’s Health, Education, Labor and Pensions Committee. Its 615 pages are filled with the usual junk DNA of conforming amendments, legal definitions, and forbidding references to subsection (d)(4)(B) above. The drill-down into technical detail is easily lampooned, as when the bill orders the Health and Human Services Secretary to perform “tooth-level surveillance” in an epidemiological survey. Such minutia go with the territory in complex legislation governing one-sixth of the U.S. economy. I’m surprised the draft is only 615 pages.

Hiding in plain sight are bigger items. Section H proposes a new voluntary insurance program called CLASS (Community Living Assistance Services and Supports). This ambitious proposal affects millions of people, not to mention every level of American government. Policy holders would pay premiums which would finance cash benefits for people who need help with activities of daily living, who could use these benefits to support family caregivers or to purchase other help. This provision has received very little media coverage. Outside a small community of budget wonks and disability advocates, few Americans know that this is there.

Despite the public health community’s best efforts, health care financing and insurance issues dominated health policy debate during the 2008 presidential campaign, and pretty much crowded out other important health issues. Partisans on all sides happily invoked broader population health issues as a rhetorical trope. Yet when the real bargaining started over scarce resources, essential activities such as reproductive health services, substance abuse treatment, STI/HIV prevention, and measures to support basic public health infrastructure were typically pushed aside. Prevention and primary care are often neglected within the health care delivery system itself, even as increasing resources are devoted to complex tertiary care.

But much of the bill’s fine print is comforting: it shows unexpected attention to my own area of public health. It goes some distance to address these difficulties. It proposes a $10 billion Prevention and Public Health Investment Fund, and would devote new resources to clinical and community preventive services. Especially heartening was some gobbly-gook in section 2708(A)(1) , which requires insurers to cover “items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force.”

Despite its intimidating structure, such language provides a nice illustration of how comparative effectiveness research allows our society to judiciously expand access to needed services of proven value.

The Preventive Services Task Force is an independent panel of physicians, public health experts, and health services researchers who systematically review the available evidence and recommend what should be routinely provided in clinical preventive care. Right now, many valuable preventive services go uncovered, sometimes because they do not save money for the insurer despite providing important patient benefits, sometimes because we the patients do not value them as highly as we should, sometimes because patients and insurers are behind the times about what we know actually works.

When evaluating a medical or public health intervention the group awards the grade of “A” when there is high certainty derived from rigorous studies that consistently find substantial patient benefit in representative populations. It awards the grade of “B” when the evidence isn’t quite as strong, but when there is high certainty of at least moderate patient benefit, or at least moderate certainty of something better.

The Task Force is no pushover for the medical and public health communities. Many valuable interventions are difficult to verify through the kinds of studies that would merit an “A” grade. I sometimes wish they were less skeptical, as when they awarded a grade of “C” (making no recommendation for or against) to routine HIV screening for adolescents and adults with no specific risk-factors. On the whole, this creative tension is a good thing. The Task Force forces clinicians and public health practitioners to field high-quality studies which actually demonstrate that pet interventions work. That’s a difficult but justified standard when one requests billions of dollars in scarce public resources.

Some commentators have attacked the creation of the Task Force and similar bodies as a back-door strategy to ration care. This is wrong. Experts across the ideological spectrum from Administration official Peter Orszag, director of the Office of Management and Budget, to Republican Gail Wilensky (pdf) advocate greater use of comparative effectiveness research to improve both the quality and the efficiency of American medical care.

This is a hard sell, for all sorts of obvious political and economic reasons. Yet as national health expenditures exceed $2.4 trillion, the arguments for evidence-based policies are becoming hard to avoid. As Sigmund Freud once put it, the voice of reason is quiet but insistent. It will not rest until it has gained a hearing.

Harold Pollack is a public health policy researcher at the University of Chicago’s School of Social Service Administration, where he is faculty chair of the Center for Health Administration Studies