Survey shows opinion leaders, Bush disagree on health policy

As President Bush begins his second term with an emphasis on medical malpractice reform, a survey of health care experts and innovative thinkers conducted by the Commonwealth Fund has come up with a very different perspective on what can and should be accomplished over the next five years.

Commonwealth Fund president Karen Davis says the survey asked opinion leaders to identify the most important issues for Congress’ health policy agenda over the next five years and to list their top five priority solutions for addressing the issues of rising health care costs and improving quality, next steps in Medicare reform, and how best to cover the uninsured. "The results [318 respondents from 1,155 surveyed] show broad consensus in a number of areas, a divergence of opinion in others, and a few surprises along the way," she reports.

The survey revealed widespread agreement that expanding coverage to the uninsured should be lawmakers’ top priority. That response cut across all groups represented in the survey population — academic and policy experts, as well as leaders in health care service delivery, health industry, business, consumer groups, and government. There also was considerable agreement on reforms needed to accomplish broader coverage, options that Ms. Davis says suggest an incremental approach rather than radical overhaul.

Improving the quality and safety of medical care, including increased use of information technology, was ranked as the second most important priority for Congress, followed by reforms aimed at ensuring Medicare’s long-term solvency and addressing the issue of rising health care costs. "That costs ranked fourth on our experts’ priority list is a bit surprising given all of the public, political, and media attention that the rise in health care expenses has generated over the past year," she adds. "Also surprising, malpractice reform, which the administration and Republican congressional leaders have expressly listed as a legislation priority, ranks well down the opinion leaders’ list, as do actions designed to control Medicaid costs."

There was limited consensus among opinion leaders on the best way to cover the uninsured, but the top two approaches were allowing individuals and small businesses to buy into the Federal Employees Health Benefits Program and expanding Medicaid/CHIP. Those in the insurance industry appear to favor the Medicaid/CHIP expansion approach, as do consumer and advocacy group leaders.

Ms. Davis says allowing uninsured people to buy into Medicare, implementing some form of Medicare-for-all system, also had a surprising degree of support, not just in the academic/research sector, but also in the health care delivery sector, although an incremental approach to reducing the number of Americans lacking health coverage seems far more likely than a more basic system overhaul.

"Perhaps the most surprising finding, again given the amount of public and political attention the concept has received, is the lack of enthusiasm in this survey for health savings accounts or tax credits to buy individual health insurance," Ms. Davis notes.

When asked about potential solutions to the problem of rising health care costs and improving quality of care, respondents came together in large numbers on three approaches — pay for performance in which providers are rewarded for efficiency and effective disease management; increased use of information technology; and greater availability of public information on provider performance and comparative quality and costs. Much further down the list was any notion of greater patient cost sharing, again somewhat surprising given the attention being paid to consumer-directed health care. Also ranking quite low was importation of lower-cost prescription drugs, which has engendered considerable attention in Congress.

For Medicare reform, there was broad agreement on three strategies — government negotiation of prescription drug prices (not supported by drug industry opinion leaders), linking incentives in physician payment to quality performance, and increasing premiums for higher income beneficiaries.

"We consider the results of this inaugural opinion leaders’ survey to be an excellent starting point for a thoughtful discussion of the difficult issues our policy-makers must address in the next few years," Ms. Davis explains. "Our findings are especially interesting when viewed in concert with the results of some recent public opinion polls on similar issues." She notes the November/ December 2004 Kaiser Family Foundation Health Poll that asked the public to choose the most important issue for the president and Congress to address among several specific health care issues. Some 29% said increasing the number of insured Americans was most important, followed closely by lowering health insurance cost (25%). In an open-ended question, nearly half of those polled said health care costs was the most important issue for government to address, followed by access to care.

And a December 2004 survey by GOP pollster Linda DiVall found that, in terms of importance, the public ranked expanding Medicaid to cover the uninsured and allowing importation of drugs from Canada well ahead of issues such as malpractice reform and tax credits to buy health insurance.

Commenting on the survey results, respondent Christopher Jennings, president of Jennings Policy Strategies, who was a senior health advisor to President Clinton, said political progressives should push their belief that all Americans should have access to affordable and reliable health insurance and that all patients should receive health care that is accountable and safe.

"First, we should aggressively promote the common-ground agenda of modernizing the nation’s health system to include a technologically coherent infrastructure that enhances efficiency, improves safety, and encourages accountability," he wrote. ". . . If private and public players wish to ensure greater value for their investment, they must be more willing to use their purchasing leverage to achieve this end. Second, as we work to improve our health care system, we must expand access to it. We cannot be satisfied with making the system more responsive to the fewer number of Americans who can afford it. It must be an economic and moral imperative that we increase access to affordable, reliable insurance. We should start by finishing up unfinished business — ensuring that all of our nation’s children have coverage."

Jennings said federal policy-makers should give financial incentives to states to expand Medicaid and SCHIP coverage and enroll all eligible kids. They also, he said, should provide tax credits for those up to 400% of poverty to purchase qualified insurance, perhaps in a separate insurance pool with the Federal Employees Health Benefits Program. In return, parents can and should be required to purchase health care coverage for their kids. Third, progressives must be aggressive and effective at fighting policies that will in all likelihood make things worse, particularly for those Americans who need insurance the most. He cited policies that political progressives should fight as a Medicaid block grant or cap, health savings accounts, and association health plans.

Another respondent, Project HOPE senior fellow Gail Wilensky, said that while Republicans have expressed a number of helpful health care reforms, a dose of realism is needed as leaders look ahead. First, there likely will be little new federal, or state, money for major expansions in health care coverage. Tax cuts are unlikely to be rolled back, she said, and President Bush has announced second term plans to pursue tax simplification and Social Security reform, both of which will keep busy the congressional committees that would take on any new health legislation. "The most important first step is to implement the Medicare Modernization Act," she said. "Implementing this measure right and on time will not be easy. Doing so will primarily involve the administration, but ultimately Congress will need to provide legislation to correct the inevitable problems that become apparent during implementation."

Improve patient safety

Ms. Wilensky’s second recommendation is to pursue the widespread agreement that the United States needs to improve patient safety and reduce medical errors. These are issues that have been embraced by both parties, she said, and by the Congress and the president, and taking effective action need not require substantial new federal funds. Her third goal is to follow up on substantial agreement that the information side of the health care system needs to be made as sophisticated as medicine’s procedure and device side. Less clear, she wrote, is how to accomplish this, but new legislation undoubtedly will be needed and could lead to movement forward. Her fourth priority is medical liability reform because the president has spoken out on it and it increasingly has been raised as an issue affecting access to health care, while her fifth topic is to find ways to improve and expand access to care while staying within likely budget constraints.

"Finally, a word of caution to the uninitiated about survey reporting: The Commonwealth Fund survey had a response rate of 28%. This is not a bad response rate for an on-line survey. But it means that 72% of those sampled did not respond, and it is not clear whether those that did respond are representative of the entire sample," Ms. Wilensky added.

(To see the survey instrument, results, and other materials, go to