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Health-care costs must be reined in, former health secretary believes

This article first appeared in the St. Louis Beacon, March 30, 2012 - Dr. Louis W. Sullivan, former Health and Human Services secretary under President George H.W. Bush, feels a sense of deja vu about health reform -- of having been there and tried to do that.

He comes to St. Louis next month during a period when the health-care law is a hot topic both in Washington and in Jefferson City. He will speak at 4 p.m., Wed., April 11, at the Eric P. Newman Education Center at Washington University. 

Sullivan, the founding dean of the Morehouse School of Medicine, co-chaired the President’s Commission on HIV and AIDS from 2001-2006. These days, he's heading the board of the National Health Museum, which is expected to be built in Atlanta, with the goal of improving health and enhancing health literacy. In addition, he is the chair of the Sullivan Alliance, based in Washington, that seeks to increase minority representation in the health professions.

His interview with the Beacon this week was edited for length and clarity.

President George H.W. Bush introduced a health-reform bill in 1992. It got nowhere, but the political climate seemed milder then. Do you ever think about how Washington has changed from then to now?

Sullivan: Oh, yes, I think about the comparison. I would say that there was a significant overlay of politics. But there wasn't the divisiveness, the bitterness and the gridlock that we see now in Congress. There was still a spirit of coming together to get things done, at least to talk to each other. But the political environment has become so poisoned that just the act of talking (with someone on the other side of the aisle) is considered almost un-American. This is really a very unfortunate situation because we elect people to Congress and the presidency to get busy solving problems. Unfortunately, the spirit in Washington now is not a healthy one. That, I think, has to change. They are there to serve the people and not there primarily to score political points, and that's what I regret about the current situation.

In the context of the current debate over health reform, do you think a mandate is the right way to go?

Sullivan: It would be great if we could find a way to do it without a mandate. But, philosophically, I am not adamantly opposed to a mandate. I don't really see this being the slippery slope. It's fundamentally a question of spreading the risk. I agree with the argument that everyone uses the health-care system sooner or later, and those who are not insured are being given care that costs the rest of us, who have insurance, through our taxes or increased premiums. It is only fair that those who can afford it (should) have insurance so that when they need to use the system, it is not putting the cost on the backs of other people.

There was no mandate in the first President Bush's health proposal, but aren't there similarities between some of what he proposed and what became law under President Barack Obama?

Sullivan: We developed a health proposal that President George H.W. Bush introduced in Cleveland in February 1992. That, unfortuately, was the beginning of an election year. We had a Democratically controlled Congress and we could never get hearings on the bill during that year. In that bill, we had financial incentives for small businesses to offer insurance to their employees. We also had group purchasing cooperatives akin to the health exchanges that are now part of the current bill to make group purchasing more efficient and less costly. We also extended Medicaid eligibility to increase the number of people eligible for Medicaid services. So a number of the features in the legislation that Congress passed in 2010 were in the bill that President Bush proposed. But we got no congressional action.

Beyond the current debate, what do you see as the key challenges for the health system down the road?

Sullivan: The major one is to bring health-care costs under control. Inflation in health care has outstripped the national inflation rate, so that is really hurting our economy. Dollars spent on health care are not available for education or road building or other activities. To give you a frame of reference, we were spending about 5 percent of GNP on health care back in the mid-'60s when Medicare and Medicaid were implemented. When I became (HHS) secretary, we were concerned that the percentage of GNP spent on health care at that time was 11 percent. Now it is close to 20 percent. Every actuary predicts that at the current rate of inflation, it's going to exceed 30 percent by the year 2025. That needs to change.

So what are some ways to reduce cost?

Sullivan: It really depends on how we use the system. We have too much use of emergency care. That costs $1,000 to $1,500 (a visit) because emergency rooms, by law, must have so much backup equipment to take care of anything that comes in. The visit might have been adequately handled one or two weeks before had the patient gone to a clinic or a doctor for care that might cost $50 or $100.

We also still have billions of dollars in health-care fraud that we seem to have difficulty shutting down. We also need to focus on health promotion to a greater degree. People don't realize that things such as regular exercise, whether walking, bicycle riding or gymnastics, can reduce the incidence of heart attack and stoke. There's some early evidence that has yet to be confirmed that it might help prevent Alzheimer's. We also need to improve our diets because we have a rising tide in obesity, the highest we've ever experienced. Finally, this issue is coupled with the fact that demographically we are getting older as a population. Older people, of course, have a higher incidence of various diseases but we can help minimize (disease) by keeping our older citizens active.

This may be sound a little naive, but if we did all these things, we might not be having this conversation about health reforms.

Sullivan: There's no question about it. When I was secretary, our public health service estimated that we could reduce premature deaths (those occuring before the age of 65) by at least one-third if we could change the health behavior (contributing to) the top 10 causes of death, including heart disease, stroke, cancer, HIV/AIDS, Alzheimer's, and doing such things as buckling seat belts.

One problem is credibility -- when we say if we do this today, this will save us 10 percent of costs down the road, say five or 10 years from now.  Congress, unfortunately, is short term in its vision. We've done a pretty good job in seat belt use in the past two decades, as well as building safer cars. But we've been (lax) in keeping up with childhood immunization because diseases, such as measles, mumps and whooping cough, are less frequent than they were decades ago. So parents are not as attuned today to immunizing their children. And we have this misinformation that vaccines cause autism. There's no scientific evidence that that is true, but the information is out there, so the public is confused and some parents avoid having their children immunized.

You were on the commission on HIV and AIDS from 2001 and 2006. We don't seem to hear nearly as much about the disease these days. Is it because we're doing a better job in addressing it?

Sullivan: It is a combination of things. We've developed a number of therapies that have helped to bring this infection under greater control. It's not completely controlled yet, so there are (still) real challenges.

In October 1989, my first year as secretary, I approved federal reimbursement for AZT, the first drug effective against this virus. Today we have more than 30 drugs that have been developed against the virus. So it's under greater control. With (the new drugs) people can live longer, work, raise families and engage in ordinary activities. A good example is Magic Johnson. He was diagnosed with the virus back in 1988.

But we still have a significant number of people who are infected every year.

One of your major projects these days involves the Sullivan Alliance. Tell us about that.

Sullivan: Part of the effort to close the health gap between minority populations and the white majority population is to get more diversity among our nation's health professionals. The Sullivan Alliance, based in Washington, works to increase racial and ethnic diversity among health professionals. One third of our nation's population is nonwhite. But less than 10 percent of health professionals are represented by one of the minority groups. A number of studies show that a Latino physician or a black physician is three to five times more likely to establish their practices in Latino or black communities.

When do you expect the National Health Museum to become a reality?

Sullivan: The museum will be in Atlanta and is still in the conceptual stage. The economy collapsed in 2008 and because of that we have not launched our campaign to get funds or the land and the facility. We have a good board that includes two other former (HHS) secretaries: Joe Califano, who served under President (Jimmy) Carter and Tommy Thompson, who served under President (George W.) Bush. As the economy improves, we hope to launch our campaign. We are probably five or six years away from the ribbon cutting.

The average encounter of people with the health-care system is not pleasant. That's a problem. They don't understand how the human body works. We want to use the museum to change that so that health becomes an interesting, fascinating and captivating subject.  It will be designed to show the wonders of the body, how cells function, how nerve impulses are transmitted, how motion is coordinated. We also want the museum to serve as a reservoir of information, a national, and ultimately international, resource that people can use to get information through the internet.

Robert Joiner has carved a niche in providing informed reporting about a range of medical issues. He won a Dennis A. Hunt Journalism Award for the Beacon’s "Worlds Apart" series on health-care disparities. His journalism experience includes working at the St. Louis American and the St. Louis Post-Dispatch, where he was a beat reporter, wire editor, editorial writer, columnist, and member of the Washington bureau.

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