The Bush administration and reconstituted Congress face a packed legislative agenda, with several key health policy issues likely to be prominently featured. But how to decide which issues should be priorities for action, given that policymakers' plates will be filled to overflowing?
Lawmakers have their own agendas, of course, shaped by evidence on a particular problem, ideology, and constituents' wishes. Professional and public interest groups can be counted on to make their positions known. Public opinion is another, often highly influential source of guidance. But we thought it would be useful to try another means of informing the public debate over the vital health policy questions facing the nation—tapping the insight of a broad group of health care experts whose business it is to look beyond the day-to-day and recognize the big picture in health care.
So in conjunction with Harris Interactive, the well-known online polling company, we've developed the Commonwealth Fund Health Care Opinion Leaders survey, a collection of 1,155 experts and innovative thinkers representing a broad range of health care sectors and points of view. We'll be surveying this group regularly on important policy questions and soliciting commentaries from a number of those same opinion leaders on the major issues of the day. Our goal is not only to gauge what these authorities think about important health policy concerns but to stoke debate about how to address them by presenting a range of well-reasoned points of view on these issues and potential policy solutions.
I'm pleased to announce the official launch of this project this month. You can see the results of our inaugural survey here, as well as read commentaries from Christopher Jennings, a well-known health policy analyst and former Clinton White House health policy advisor, and Gail Wilensky, Ph.D., senior fellow at Project HOPE and former administrator of the Medicare and Medicaid programs. You can also learn more about the survey's methodology.
Our first survey asked the opinion leaders to identify the five most important issues for Congress' health policy agenda over the next five years, as well as to name their top five priority solutions for addressing the issues of rising health care costs and improving quality, next steps in Medicare reform, and how to best cover the uninsured. The results (318 respondents) show broad consensus in a number of areas, a divergence of opinion in others, and a few surprises along the way.
What Should Congress Do?
When it comes to Congress' policy agenda, there is widespread agreement that expanding coverage to the uninsured should be lawmakers' top priority. This holds for all groups represented in this survey—academic and policy experts, leaders in the delivery of health care services, health industry, business, consumer groups, and government. There is also considerable agreement about the reforms that should be enacted to accomplish this, options that suggest an incremental approach rather than radical overhaul. Improving the quality and safety of medical care, including increased use of information technology, is 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. Also surprising, malpractice reform, which the administration and Republican Congressional leaders have expressly listed as a legislative priority, ranks well down the opinion leaders' list, as do actions designed to control Medicaid costs.
Covering the Uninsured
Although tapped as the top policy priority for Congress, there was only limited consensus among opinion leaders on the best way to address this difficult problem, but the top two approaches were clearly allowing individuals and small businesses to buy into the Federal Employees Health Benefits Program (FEHBP), and expanding Medicaid/CHIP. Opinion leaders within the health insurance industry appear to prefer Medicaid/CHIP expansions and find the FEHBP buy-in notion less attractive, as do consumer and advocacy group leaders. Allowing the uninsured to buy into Medicare and implementing some kind of "Medicare-for-all" system 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 overhaul of the system. 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.
Controlling Costs, Improving Quality
When asked about potential solutions to the problem or rising health care costs, and how to improve quality of care, there was a great deal of consensus on three approaches—"pay for performance," or rewarding providers for efficiency and effective disease management; increased use of information technology; and greater availability of public information on provider performance on comparative quality and costs. Interestingly, the notion of greater patient cost-sharing was well down the list; somewhat surprising given the growing attention to "consumer-directed health care," the movement to give consumers more direct control over—and responsibility for—the care they choose and the costs for that care. Importation of lower-cost prescription drugs from outside the U.S., particularly from Canada, also ranked relatively low.
Whither Medicare Reform?
There was broad agreement on three strategies—government negotiation of prescription drug prices (although that option was not supported by opinion leaders in the pharmaceutical industry); linking incentives in physician payment to quality performance; and increasing premiums for higher-income beneficiaries. This last notion likely will gain more attention in coming months; the Medicare Modernization Act (MMA) includes a provision to begin implementing such an indexing notion. Opinion leaders were split on potential expansions or enhancements of the prescription drug coverage provision of the MMA, something that had generated a great deal of public and media controversy given the "donut hole" in coverage for seniors with modest incomes and mid-ranging drug expenses. Interestingly, there was little support for capping federal Medicare spending.
Advancing the Discussion
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 policymakers must address in the next few years. Our findings are especially interesting when viewed in concert with the results of some recent public opinion polls on similar issues. For example, the November/December edition of the Kaiser Family Foundation Health Poll Report asked the public to choose the most important issue for the president and Congress to address among several specific health care issues. About three of 10 said increasing the number of insured Americans (29%) was most important, followed closely by lowering the cost of health care and insurance (25%). In an open-ended question, nearly half of those polled named health care costs as the most important health problem for government to address, followed by access to care. A survey released last month by GOP pollster Linda DiVall, meanwhile, 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 such issues as malpractice reform and tax credits to buy health insurance.
We fully expect some of our results, especially those that may seem surprising at first blush, to be parsed, questioned, and criticized. And that's fine. The goal here is to expand and inform a healthy public and professional debate, not reinforce established notions or limit useful options. So as part of that ongoing effort to keep the discussion going, we invite you to take the survey yourself; we'll post the results at a later date. We also invite your comments on this survey and suggestions for topics to be addressed in the future.