As health reformers contemplate a new era of political leadership under President Barack Obama and a heavily Democratic Congress, the prospects for real change in America's troubled health care system have never looked better. Fifteen years ago, however, would-be reformers had equally high hopes as they savored Bill Clinton's "mandate" for comprehensive reform, only to watch the exercise implode, because the changes it proposed were overly ambitious.
This time, Democratic campaigners have learned the central lesson of the Clinton episode: Proceed incrementally, avoid mentioning big changes likely to scare the general public and provoke interest groups, and talk up admirable but largely peripheral innovations such as information technology and electronic medical records.
The challenge in overhauling the health care system, however, grows more acute, partly due to an aging population. Although we know good health is a product of much more than good medical care, the United States has pinned high hopes and huge sums on a highly technical and service-intensive medicine that shortchanges the other crucial points on the continuum of high-quality care, from prevention and health promotion, to primary care, to acute care, and then to chronic care.
We argue that any coherent systemwide plan must address the nation's health within a public health framework. That is not what we have now. Solutions must include proper attention to the social determinants of health—poverty, education, status and more—which often fall outside the realms of health policy and health care. The indispensible, albeit undervalued, contribution of public health is its comprehensive promotion of the health of whole populations and illness prevention.
Demographic projections lend extra urgency to the case for overdue diligence in rebalancing these systemic elements. One often hears that keeping Medicare and Medicaid sustainable is not only a herculean task in itself but also a barrier to achieving other important goals, such as covering the 45 million uninsured Americans. But lamentations over the dire fiscal prospects of Medicare and Medicaid rarely acknowledge that federal and state governments are deeply reluctant to support and expand innovations they themselves launched to enhance prevention, health promotion, primary care and care for older adults, the disabled, and others with chronic conditions. Time and again, such integrated models have shown their cost effectiveness. For example, teams of physicians, geriatricians, nurses, social workers and psychologists can work with the aged population to prevent falls, screen for depression and avoid unnecessary emergency room trips, but such integrated efforts are rare because current regulations may prohibit them and there is not enough funding. Such programs show that skillfully integrated services can improve both the quality and efficiency of services; it is crucial that we implement their lessons.
We argue, in short, for a new public health agenda that honors the field's traditional prevention mission but seeks to incorporate it into services and settings across a balanced policy spectrum. Three elements are key: First, we need strategic and conceptual perspectives that can complement and counterbalance our system's longstanding fixation on specialty care and the conquest of disease and the consequent neglect of opportunities to prevent and manage disease and chronic conditions and to promote better health. Second, we urge fresh institutional and organizational insights in integrating providers of care whose independent operations too often belie their interdependent missions. Third, reformers must closely examine the forces of political economy that often inhibit the innovations that pass evaluative muster but nonetheless languish on the sidelines. This new public health agenda may be a heavy lift for an incremental policy process, but deserves a prominent, indeed leading, role if the aim of reform is to improve the health of the American public.
© Columbia University