Time to come to terms with national embarrassment

Our nation's health policy has been to have no policy. As a result, we receive the worst of all possible worlds, a perfect storm of high costs, poor access and shameful outcomes that disproportionately impact the poor and people of color.

The incentives for health-care delivery in the United States are inverted: we reward intervention and skimp on maintenance; reimburse service volume while ignoring outcomes; and penalize efficient providers even as we reward the profligate. Health care costs twice as much as it should, underperforms in terms of outcomes, yet still leaves over 45 million people -- 17 percent of the non-Medicare population -- uninsured. Our health system is ranked 37th in the world by the World Health Organization. We are afflicted with an infant-mortality rate more than twice that of Japan or Sweden, yet despite returns of 600 percent in avoided health-care costs, we invest mere pennies from the health-care dollar in public health.

Our system suffers from a legacy of oppression, segregation and racial injustice. The United States is the only industrialized nation with an employer-based health-care system other than South Africa.

Far from incidental, at the time the enabling tax legislation was passed, segregation was the law of the land and brutally enforced. Today, workers without health benefits are still disproportionately people of color. The infant-mortality rate for blacks is a shocking 240 percent that of whites. Although African Americans represent 12.3 percent of the population, just 2.2 percent of physicians and medical students are black, less than the proportion in 1910.

The employer-based health-care system is an accident, and not a happy one. Far from intentional, it is the result of World War II-era tax policy allowing businesses to deduct health-insurance premiums to circumvent wartime wage/price controls. One sixth of the output of the entire U.S. economy, an unimaginable $2.2 trillion, is funneled into health care, with only the slightest regard for outcomes. When production is not constrained by quality or efficiency, outcomes suffer; we have only to look at the auto industry to see the result of focusing on lobbying rather than product.

While the U.S. system is dangerous to our physical health, the health-care market is hurtling toward a fiscal crisis of unimaginable consequence. Michael Levitt, then secretary for health and human services for President Bush, said that health-care spending "could potentially drag our nation into a financial crisis that makes our subprime-mortgage crisis look like a warm summer rain." Part of the problem is that the tools available to federal health policymakers are relatively blunt; there is no health-care Federal Reserve that can influence health-care inflation like the Fed manipulates money supply and interest rates.

Actually, there is -- special interests have just refused to permit it to operate as anything more than a money spigot. Medicare and other government programs now account for over 45 percent of the health spending in the United States. But when these programs were established, as a compromise to powerful health lobbies, the principles of sustainable health care were not incorporated. Thus, what was a golden opportunity to incorporate information other than price into the system became instead the start of the mad gold rush that is the U.S. health-care system.

Because there is no mechanism to examine and communicate the benefits, risks and costs of new treatments, researchers estimate 30 percent of care in the United States does nothing to improve health outcomes. Based on experience with similar institutions in Europe, the Commonwealth Fund estimates that direct savings of $368 billion over 10 years could be achieved by establishing a Center for Medical Effectiveness, using Medicare to accelerate the diffusion of best practices.

Unfortunately, there is no one "magic bullet" to save our foundering health-care system. A successful approach will require thoughtful policymaking as well as changes in our cultural expectations of infinite resources and unlimited choice. Like green energy, America will need to invent and practice sustainable health care that enhances value and improves outcomes.

□ Reward outcomes, not services.

□ Provide incentives to encourage the practice of evidence-based medicine.

□ Develop electronic medical records.

□ Establish regional systems of medical homes and off-hours care facilities.

□ Invest in the nation's public-health infrastructure.

As veterans of the environmental and anti-tobacco campaigns will attest, change will not come easily, or overnight. But we should not wait for federal initiatives to begin improving the health of our community. Healthy communities explicitly incorporate health considerations into their policymaking dialogue, and the results are measurable. Healthy communities have higher educational levels, lower employee costs, and are more attractive to business investment. With long-term benefits and minimal up-front cost, local health policy can create an environment supportive of active living and healthier eating, improving the quality of life for all of us.

■ Jim Toole is a consulting actuary with MBA Actuaries and co-chairman of the Forsyth County Health Equity Action Team. The Journal welcomes original submissions for North Carolina Voices on local, regional and statewide topics. Essay length should not exceed 750 words. Our e-mail address is: Letters@wsjournal.com. Typed essays may be mailed to: Letters to the Journal, P.O. Box 3159, Winston-Salem, NC 27102. Please include your name and address and a daytime telephone number.