UVa provost discusses pros, cons of health care overhaul

Dr. Tim Garson is executive vice president and provost of the University of Virginia, a pediatric cardiologist and a leading authority on health care reform.
Garson recently fielded questions from The Daily Progress to help explain the ongoing debate over health care reform taking place in Congress.

Q. You co-authored a book called “Health Care Half-Truths: Too Many Myths, Not Enough Reality.” What do you see as the biggest health care myth in the current debate and what is the reality?
A. The biggest current myth has to do with the “public plan.” It looks like, as of this past weekend, that the idea of the public plan may be history so it may not be terribly important to spend a terrible amount of time on it.
The idea of the public plan was to have a government-funded plan to compete against private insurers. That, while having a very unfair playing field since private insurers have administrative costs that a public plan would not, provided an option that would be the lowest-cost option for a large portion of people.
The myth was that the public plan, in my opinion, would eclipse all private plans. It doesn’t seem that way in the United States. Certainly the public plan would have had a large number of people enter that plan. But we are a country that clearly wants private health insurance, choice of a large number of physicians and hospitals, and we are a people who want to pay for what we consider to be in our best interest.
I don’t think a public plan, even had it been maintained, would have eclipsed the private system. It certainly would have changed it, in that it would have required even greater competition — which would have lowered prices and improved quality.

Q. Do you believe there ought to be some form of government-sponsored health insurance?
A. I think the systems in the United States are going to be in evolution.
It seems to me that in a 10- to 15-year time frame, there needs to be a single, seamless safety net.
Right now, we have safety nets called Medicare for those over 65, Medicaid for those over 65 and under 19, as well as some disability in between. We have academic health centers, like the University of Virginia, that act as safety net hospitals and providers with our physicians. Other parts of the country have county hospitals, state hospitals. And there are whole networks of community health centers.
The idea that all of those are separate and not related is just not efficient.
For example, if you are basically a person without kidney disease, is not blind, is not disabled and is not pregnant, between the ages of 19 and 64, Medicaid does not cover you by federal law. That’s how come we have so many uninsured. There is a huge hole in the safety net.
A single safety net should exist. We already have a single safety net called Medicare — and that is a single-payer system.
We, the people, have already accepted a single payer in Medicare, we’ve accepted a single payer in Medicaid. We already have single-payer systems.
It feels to me that we should knit together all those single-payer systems and have a single, single-payer floor for the care of everybody in the United States.
I don’t feel that that’s going to be politically acceptable for several, if not 10, years.

Q. What’s your take on the current health care proposal before Congress?
A. There are a number of plans, but the plan that has received the most attention recently is the House plan that comes out of three committees. We haven’t yet seen the full Senate plan.
The House plan has a number of important goals that it addresses. People may disagree with how to achieve those goals. But to me, and to a lot of us who have been working on the uninsured for 20 years, the idea that health care coverage will be supplied to everyone is terrific. That’s the most important goal that we can achieve in health care: to make sure that everyone is covered.
The next most important goal is that the means by which the coverage happens allows people to afford it and subsidizes people who can’t.
One of the things that was found in Massachusetts is that when [that state’s health care] plan originally was rolled out, there were 65,000 people who by the definition of the commonwealth of Massachusetts could not afford health insurance. So they had to remove the individual mandate [for coverage]. I believe that everyone should have health insurance. But if you’re going to require everyone to have health insurance, it has to be affordable to those people who are expected to pay for it. And when you say ‘it,’ that insurance means they are covered for the vast majority of illnesses and well care that they should have.
The problem is, can we afford to cover everybody?

Q. Can we?
A. Everybody seems shocked that the price tag is $1 trillion over 10 years. Well, we have a very similar figure to that in our book from three years ago. That’s not a surprise. If there are 50 million uninsured, and you insure people at only $2,000 per person, that’s $100 billion per year. And a $100 billion times 10 is a $1 trillion. It should not be a shock to everyone that covering the uninsured is expensive.
The interesting debate has been around how much we can save in order to pay that $100 billion. It really seems to me that there is significant waste in the United States’ [health care system] that every one of us at different levels can attack.
A marvelous New Yorker article by Atul Gawande pointed out the most expensive place to practice medicine or receive medical care in the United States is in south Texas. When he went there to examine why they were so expensive, the interviews he carried out with physicians pointed out that they were doing all sorts of things that really didn’t need to be done. This seems to be a characteristic of communities.
There are communities that are lower priced, such as Salem, Oregon. And there are communities that are higher priced for the same disease, such as south Texas, such as New York, such as Miami.
There is a 300 percent to 400 percent variation — three to four times the variation — in the amount of services done in a place like Miami than a place like Salem, Oregon, for the same kind of problem. Three times the rate for coronary bypass surgery. Three times the rate for stents. Three times the rate for back surgery.
There are all kinds of reasons why physicians practice differently in different parts of the country. We hope the most important reason is there is an actual difference in how they think they should take care of a patient. There are others. Malpractice. Difference of income. All kinds of reasons.
Over the next several years, practice guidelines that are created by our own physician groups are going to get better and better at saying, no, this is the right way. This is what’s needed and this is what’s not needed. The American College of Cardiology is developing what’s called “appropriateness criteria.” When is it right to do this kind of imaging? Imaging is very expensive. X-rays? Nuclear tests?
The American College of Cardiology has taken the lead on appropriateness. The other thing they’ve done is started registers, where physicians submit their data nationally and it becomes a lot more visible that if the results are the same and one group of physicians is doing a lot and one group of physicians is doing a little, maybe you don’t need to do a lot. There’s a lot of waste in how physicians practice.
The better data we have, the better it will be. This leads to the concept of the electronic medical record, which is probably the single most important tool we have for improving quality and reducing cost at the same time.
Imagine having the ability nationally to get data on different kinds of patients and help doctors say, you know what? That patient is not unique. I can look in the database and find there are 87 patients exactly like my patient, and here is how physicians treated those other patients.
It’s about getting better and better information to the physicians about how to make decisions in the most effective and cheapest way. Most effective first. Cheapest second.

Q. Do you see health care coverage as a right?
A. We could spend a whole lot more time discussing the definition of what’s a “right” rather than really answering the question of whether everybody should have it.
Should everybody have it? Yes.

Q. Do you see any problems associated with health care reform?
A. In Massachusetts, they have a tremendous model. I give them tremendous credit for doing a bipartisan job for putting in health care reform, and it’s working. They took their uninsured from 10 percent to 2.6 percent. It is not likely that anywhere will get a lot lower than 2.6 percent.
They now have 400,000 people with a health insurance card. But the time to see an internist has gone from 33 to 52 days. So now we have tremendous physician and nurse shortages.
We are about to provide 50 more million people — I hope — on the system that is now stressed with a shortage of physicians and nurses. We are in the midst of providing insurance coverage, but we’re also dealing with a problem of access.

Q. You recently co-authored a study that recommended strategies for curbing obesity that included a 10 percent tax on fattening foods, new limits on junk food advertising and tougher requirements for nutrition labeling. Why is this necessary?
A. The entire basis for this was to go back and look at how smoking was attacked. Smoking 45 years ago was not very different from obesity now. A very difficult problem. Killed people. A hundred thousand people or more die due to obesity every year. So the problems were not different. We went back and said, what worked?
Turns out, three things worked. One was simple labeling. Many, many countries have much more Draconian labeling than we do. They have pictures on cigarette packs.
There are 50 countries that restrict advertising, especially of food that would be aimed at children under 15.
Thirdly, there is the tax. The World Health Organization tells us that the cigarette tax is the single most effective method worldwide over the last 45 years that has reduced smoking.
It turns out that the calculation of a 10 percent tax on what would be considered fattening food — which is, unfortunately, a third of what we eat — would generate $522 billion every 10 years. That’d pay for half of health reform.
We presented three options, each of which is very difficult. No one is saying these are not extreme. Of course they’re extreme. No one is saying we must do any of them. What we did was present options to the American public to consider.