by Bill Frist
We can eliminate billions of dollars now being spent on administrative costs. One way is to standardize and simplify the complex tangle of bureaucracy that characterizes our current insurance system. The existence of hundreds of private and public insurance plans means that health-care providers must navigate an incredibly complex and confusing ocean of paperwork, regulations, and restrictions, while patients and families find it almost impossible to intelligently compare plans, choose among them, and control the cost burdens borne by them (and their employers).
Forget the single-payer system—that is, a single government-run insurance program like those in Canada or Britain. Recall my personal experience with Britain’s National Health Service, where blunt rationing by a few government officials and politicians at the top sharply limits access to the latest developments in health science. Today, you frequently hear practicing physicians speak positively about single-payer systems, mainly out of frustration with the paperwork and myriad regulations that they have to put up with every day as they care for patients. And although systems like that in England do a much better job of guaranteeing basic levels of care for everyone, including the poor, over time a single-payer system that relies on the monopsonistic purchasing power of government discourages innovation, new medical discoveries, revolutionary research, and medical progress. In the long run, the quality of treatment enjoyed by Americans would irreparably suffer under a single-payer program.
Standardizing paperwork and making various health-care plans easier to compare would reduce the hours spent by providers in managing red tape and enhance the ability of families to find the right kind of coverage for them. This requires government regulation. Consumers could then prudently shop, and their millions of daily decisions could shape the system toward value.
There is more to good health than good health care. For the first time, we are raising a generation of children who will live sicker and shorter lives than their parents. Where (and how) we live, learn, work, and play has a greater impact on how long and how well we live than medical care. We now know that brain, cognitive, and behavioral development early in life are strongly linked to health outcome later in life. Policy makers must approach health with the twin philosophies of encouraging individuals to make responsible personal choices and removing obstacles that prevent too many Americans from making healthy choices. Our nation must develop a culture of health.
It’s also important to take a step back and ask the larger question, “What are the most important determinants of health in our society today?” Importantly, they are not the doctors, the hospitals, and the health services that might first come to mind. Instead, they are behavior and genetics. They are the so-called social determinants of health—things like diet, exercise, smoking and drinking, basic education, and socioeconomic status. The policy maker has a hand in affecting each of these; indeed, the most overlooked way to improve the health of our citizens is to focus on these social determinants. Improving K–12 education will improve health, which is why I’ve started a citizen-initiated statewide collaborative called Tennessee SCORE. SCORE is pulling together people from all around the state to address best practices in K–12 education in Tennessee. Improving K–12 education will improve health.
Today, health-care reform is at the top of the national agenda, both for the Obama administration and for Congress. Some in the media and on Capitol Hill express concerns that President Obama is being overly ambitious in trying to reform health care in the midst of the worst economic crisis since the Great Depression. They wonder whether our nation can really afford to fix the health-care system at a time when millions of people are out of work, the flow of credit has practically ceased, and the world economy is actually shrinking.
I would turn the question around and ask: Can we afford to do nothing about a wasteful and inefficient health-care system that drains billions from our economy, weakens the competitiveness of thousands of businesses through excess costs, and yet fails to deliver basic care to far too many of our citizens? We have a moral responsibility, I believe, to see that every single American has affordable access to health care. The need to improve the productivity, fairness, and consistent quality of American health care is deeply intertwined with our economic problems. Fixing health care will help the economy. Thus, I strongly support the administration’s determination to act on both fronts simultaneously, great as the challenges will be.
In today’s movement for health reform, most of which I strongly support with more egalitarian access and an intense and sharp focus on value (that is, outcomes and results for every dollar invested) and quality not just quantity, I do have one fundamental big red flag to wave: Government cannot run health care.
Although a case has been made that the government can run the automobile industry and banking industry (though I am not convinced), health care is too personal and the science and technology are moving way too fast for slow-moving, lumbering government control. Winston Churchill wisely mused: “It has been said that democracy is the worst form of government except all the others that have been tried.” I’d say the same, having been a doctor in the British National Health Service, having worked for years in the federally-run Veterans Administration hospital system here at home (both socialized systems), and having served at the highest level of our government, when it comes to whether government should trump competition, markets, and a business approach in health-care discovery and delivery.
Why?
First, politicians run government. My colleagues in the Senate aren’t businessmen; they are politicians. That is who they are and that is how they will behave. They think short-term: Washington is a two-year town and not a twenty-year town. Remember, Medicare is going bankrupt in just eight years! But the politician is always focused on that next election—the one in two years. And politicians, since the rare exception is the one who comes to town as a self term-limited citizen legislator, will be loyal first and foremost to the immediate whims of those citizens who will elect him in the next election. As the senator from Tennessee, I, of course, will look first and foremost to the interest to the almost 7 million people from Tennessee. And that is what a politician should do, but that is not necessarily what one running the enterprise of health care should do.
Second, government is inefficient. Thirty percent of the health-care dollar is wasted through overuse, underuse, and misuse. The only way to root out the waste is achieving efficiency. And the federal government is not good at efficiency. In fact, the body I led, the Senate, was specifically designed by our Founding Fathers to be inefficient, slow, and deliberate and removed from the passions of the people. The Senate’s proverbial role, as defined by Thomas Jefferson and George Washington, was to be the saucer into which the hot tea is poured to be safely cooled. And that is why we have unlimited debate and why any single senator can bring the body’s progress to a halt. That’s good for government but not good for the entity running health-care delivery.
This same inefficiency is engrained in our three branches of government. The president of the United States is our nation’s leader, but his hands are tied without action by the coequal branch of the U.S. Congress. Such slowness and inefficiency is not consistent with the breathtaking speed at which proteomics and genomics are being introduced daily to save lives of those with cancer.
Third, government spends too much too irresponsibly and, from a former lawmaker’s perspective, this is because the government is not spending its money, it’s spending someone else’s (your) money. “Let’s start a new program that will do some good; we can use someone else’s money to do it.” And the government too often “cooks the books.” Government tells us there is a trust fund for Social Security and for Medicare. Is there really? Not by the generally accepted accounting standards. Have we really been running trust fund surpluses for years, or are these just IOUs and government borrowing?
I encourage my colleagues in Washington who seem to be embracing hugely increased government spending and h
eightened government regulation not to go too far in ignoring the powerful, transforming forces of competition and the profit motive. Unfortunately, government tends to have a strong bias against competition; it does not tolerate having some entities win and some lose based on value. Can government compete on a level playing field in health care? Some believe so, but there is no historical evidence to support this.
So let’s have government define the playing field and set the rules. But then let’s have individuals and private enterprise, with all their innovation and transforming potential, be the players who lead us to a more equitable, efficient, and effective health-care sector.
Now that I am out of politics and public office, I am free to engage fully. I will continue to make my voice heard as the health-care reform is discussed. The heavy lifting will not come with passing a reform bill, but rather with how the legislation is implemented by the private sector. I will continue to speak out on the lecture circuit, on TV and radio, and through articles and interviews in the print media. In addition, we must train a whole new cadre of leaders who can look at the challenges from a new perspective, in a much more integrated and even out-of-the-box way. With this in mind, I taught two health economics courses last year at Princeton, and this year I am breaking new ground by teaching a truly multidisciplinary course that includes fifteen second-year business students and fifteen fourth-year medical students at Vanderbilt University. I am downloading everything I know about medicine, policy, economics, and politics to this class of bright and committed students; they are the generation who can bring fresh ideas and cross-cultural business/medical solutions to the problems that plague us. In time, I hope to bring students from the law and nursing programs into the same course. I believe it is in settings like this that we can cultivate the cross-disciplinary conversations that will be essential to building a health-care system where the incentives for all participants are aligned on value for the patient. The students of today are our salvation for tomorrow.
Over the past three decades, health care has been a black hole of American politics—a seemingly insoluble, incredibly complex set of problems that most in government would rather ignore, or tinker with around the edges, rather than risk their political capital in tackling head-on. But I’m optimistic that we will soon make real progress in collectively developing meaningful solutions. Health care is such a basic necessity—and the economic and human costs of the existing system are so enormous and painful—that Americans of every political persuasion are finally ready, I believe, to coalesce around commonsense approaches.
THE SECOND OF MY THREE BUCKETS OF CURRENT ACTIVITY IS AN extension of the first: the use of private capital and markets to supplement what the government is investing in health services. Government must set the ground rules and establish the broad regulatory framework, but the delivery of health care should remain within the province of the private sector (with the exception of the Veterans Administration system). The private sector brings resources, innovation, efficiencies, and dynamism to the field, which is why my own instincts lean heavily toward creative entrepreneurial ventures. I’m not only a firm believer in the robust value of private enterprise, I’ve also been a practitioner of it. I’m convinced that the ethical pursuit of profit can be a powerful force for good in the world—a driver of economic growth, innovation, and enhanced quality of life for everyone from the very poor to the affluent. I’m fascinated by the managerial challenges involved in designing, building, and running a successful enterprise. And my brother’s experience in founding and developing HCA has demonstrated that for-profit organizations have a vital, constructive role to play in bringing improved health care to millions of people in America and around the world.
Working as a partner with Cressey & Company LP, a private equity firm specializing in middle-market health service investing, I help guide investors’ funds neither into brand-new start-up companies nor into large, successful firms, but rather into established midsized organizations that we feel are poised for growth. The businesses that have attracted our interest are involved in a wide range of health-care services, from hospice and home care to behavioral health and laboratory testing. The common thread: All are designed, in one way or another, to improve quality of care for the patient, to broaden access to treatment, or to deliver higher value for the patient through better outcomes and lower costs. Lasting health reform will require true public-private partnerships, and through Cressey & Company, I am focusing today on the private side of this collaboration.
MY FINAL BUCKET CONSISTS OF MY ACTIVITIES IN THE GLOBAL health and poverty arena. This is an outgrowth of that first trip to Lui, Sudan, where I saw with my own eyes the terrible human cost of poverty as well as the potential good that caring citizens with a heart to serve can do. Over the past thirty years, 5 billion people in the world have progressed by most socioeconomic measures; but a billion have gotten progressively poorer. I’m focusing on the “bottom billion,” those living on the equivalent of one dollar or less a day, who lack access not only to basic health care but to many of the fundamental conditions that make good health possible: clean water, sanitation, nutritious food, decent shelter.
The good news is that today we know the many things that can work to reverse the plight of those in need around the world. Of the more than 9 million children under the age of five who die every year, two-thirds of those deaths are preventable by inexpensive, proven methods—like simple oral rehydration for treatment of diarrhea, cheap antibiotics, malaria bed-nets, and vaccines. Thus today I work closely with non-profit organizations: recently traveling to Bangladesh with Save the Children to study the use of vitamins to save the lives of newborns, and visiting Mozambique where I performed surgery for later-stage tuberculosis and visited an innovative housing project run jointly by Africare and Habitat for Humanity. These programs work, and are making remarkable, sustainable progress.
Along with my colleague Jenny Dyer, with whom I had worked previously when she was working with Bono on faith-based initiatives, I oversee a remarkable young foundation called Hope Through Healing Hands (see Hopethroughhealinghands.org), which serves as the umbrella organization for all our global health activities. To date we have supported HIV initiatives for over thirty thousand of the poor in Middle Tennessee through Project CORE; provided resources to Save the Children to support five thousand community health workers in the poorest communities around the world; established health education resources for more than one hundred thousand Latino churches around the world; invested in the faith-based international HIV/AIDS relief program of Franklin Graham’s Samaritan’s Purse; and contributed half a million dollars to the building of an education center for HIV-affected families with the remarkably successful TASO program in Uganda. In 2010, we are sending eight student-scholars to Africa and Central and South America to gain experience and understanding as they serve the neediest of the world. We started this organization from scratch just five years ago. It is non-profit, built on the shoulders of thousands of volunteers, and a powerful example of how something that starts as a small idea can rapidly grow to have major global reach.
I still keep one foot in Washington through my board participation with the Millennium Challenge Corporation (MCC). It’s a fairly new, U.S. government–funded global development organization whose goal is to reduce poverty by promoting long-term economic growth in some of the world’s poorest nations. The MCC demands absolute accountability for the taxpayer money we invest. We do so by using seventeen objective indicators of good governance, economic freedom, and wise investment in human resources to determine those countries where substantial U.S. taxpayer assistance through public-private partnerships will have the greatest impact in reducing poverty in a sustainable way. MCC investments focus on infrastructure, agricultural productivity, health care, water, sanitation, education, and private-sector development. This is one development program where I know taxpayer dollars are being used wisely for sustainable impact in the developing world.
And finally in this third bucket of global health, I continue my medical mission trips overseas. Over my years in the Senate, I visited or worked as a physician in thirteen African countries, including conflict areas such as Darfur, southern Sudan, and the Congo. Now I can stay a little longer and do a little more. In July 2008, I led a small delegation to Rwanda with Tom Daschle for the ONE Campaign, to study the effectiveness of current U.S. initiatives such as PEPFAR, the MCC, and antimalarial programs. Though I have spent much time decrying the lack of civility and partisanship in Washington, D.C., I also wish Americans could witness the inspirationally positive occasions like our recent trip to Rwanda. It was a motley crew that spent four days together in a tiny bus traveling the countryside of the most densely populated country in Africa: Tom Daschle; Cindy McCain (wife of then presidential candidate John McCain); John Podesta (president and CEO of the Center for American Progress, former chief of staff to President Clinton, and head of President Obama’s transition team); Mike Huckabee (former Arkansas governor and 2008 Republican candidate for president); and me. Did you see coverage of our journey on the news? I bet not. It’s a side of Washington that is rarely featured in today’s hyperpartisan media. Let’s build on trips like this.