Interview With Drew Altman: Kaiser Family Foundation

'At the end of the day, the enemy is us.'

Drew E. Altman, PhD, is president and CEO of the Henry J. Kaiser Family Foundation, a nonprofit foundation in Menlo Park, Calif., with major facilities in Washington, D.C. It develops and runs its own research and communications programs, often in partnership with outside organizations. Altman was a former commissioner of the Department of Human Services for the state of New Jersey and served in a senior position in the Health Care Financing Administration in the Carter administration. Altman is a member of the Institute of Medicine and the American Academy of Arts and Sciences. WebMD's Washington correspondent, Todd Zwillich, interviewed him on the state of the nation's health care and how the election might affect it.



How big an issue is health care to the nation?

It looks like we're at the beginning of our next great debate on health care, the first since the early 1990s. It's becoming a real political issue again. Still, there's no guarantee reform will happen. We're not back at the levels of public concern we saw 15 years ago, and the war in Iraq still dominates the political landscape. We do know health care is a top personal concern. For regular people, the problems are objectively worse since the early 1990s. We've had almost 15 years of growing costs, and we've seen the ranks of the uninsured continue to increase most years by 1 or 2 million. Average Americans with coverage are also concerned about their eroding benefits and the cost of those benefits, and those have both gotten worse over time, not better.

Is the health care system broken?

We're quick to throw around words like "broken" and "crisis," but I don't think there is a way to define them when it comes to health care. We've been in a state of "crisis" ever since I've been involved in health policy. I would rather say we have very serious problems and have been unable to come to any meaningful agreement about how to deal with them, particularly in Washington. Those problems are so big now unfortunately that they must be dealt with at the national level. The intensity of concern about health care goes in cycles. The country gets the most concerned when costs are risking, the uninsured grow, and the economy is bad. Right now we have two of three. If the economy goes south, that's when you'll see concern really heightened.


What should we do to lower health care costs?

That is the toughest problem we face. We have not even had an intelligent or informed debate on lowering cost since I've worked in health care. Almost every study shows the real drivers behind costs are advances in medical technology, the zealous use of technologies, including drugs. But the American public doesn't know that. They think the reason cost go up is because companies are making too much money and they're being ripped off. As a result, Americans are not in a frame of mind to sacrifice anything to control costs. While the search for villains leads us to insurance companies, drug companies, and hospitals, at the end of the day the enemy is us. We always want the best and we want it now. Until we're willing to have a meaningful discussion about why costs go up, we have no chance of really addressing it.

How -- or should -- we try to cover the uninsured?

The one bit of progress we've made since the early '90s is that then there was a disagreement about whether 47 million people without insurance was even a problem. We've gotten past that one. We now realize that it is indeed a national shame. As a former state cabinet officer, I have a sense of what states can do about this problem. While some pacesetting states can show the way, real reform has to be achieved nationally. The national debate can be informed by what's going on in states but not solved by it. But if you look ahead to 2009, it is almost unthinkable that the underlying differences between liberals and conservatives will be transformed to a degree that it will satisfy everyone. It's going to be a centrist bargain in 2009 or no bargain at all. So advocates of the most liberal and most conservative solutions are going to have to be willing to compromise. If not, we will get nowhere.

What should we do to make prescription drugs more affordable?

What is fueling the public anxiety now is the whole panoply of out-of-pocket costs. Prescription drugs are like the gas prices of health care costs. People see them every time they go to the pharmacy. But it's premiums, co-pays, and deductibles all together that really drive costs, so we have to keep that in context. I think at some point we need some way -- either through public or private means -- to review new technologies of all kinds and determine whether they actually bring new benefits to the public or just new profits to companies. We should happily pay for all new technologies that bring new benefits, but we should not pay for those that have no new benefits for people over the old ones and only produce profits. And we don't have that mechanism now.

How important is prevention to any health care policy we pursue?

Prevention is critically important. It is important for health, and popular politically, to talk about it. But there just isn't a lot of evidence that it saves a lot of money. And we probably shouldn't be so lax in letting politicians pretend that it will, or that if we do more prevention it will pay for covering the uninsured. Its principal benefit is in providing better health, but it is yet to be demonstrated that it is will save a lot of money. Many targeted preventive services do save money, but overall we just don't know if prevention is a saver. We should do it for other reasons besides money.