It has been a year since I wrote about the Citizens’ Health Care Working Group (CHCWG), and it’s time to review what has happened since then. The Group, a committee of 14 members, was created by the Medicare Prescription Drug, Improvement and Modernization Act of 2003, Sec. 1014, to provide for the American public to "engage in an informed national public debate to make choices about the services they want covered, what health care coverage they want, and how they are willing to pay for coverage."

Between last fall and this spring, the Group held a series of about 50 community meetings at which they heard from over 25,000 people. On June 1, they issued a set of interim recommendations on "health care coverage and ways to improve and strengthen the health care system based on the information and preferences expressed at the community meetings." That was followed by a 90-day public comment period that ended on Sept. 1, during which they heard from over 4,000 individuals. The Group is using those comments to refine its proposals before issuing final recommendations to Congress and the President at the end of September. The Medicare prescription drug law requires five congressional committees to hold hearings on the report in 2007.

To access their Interim Recommendations with commentary (Updated on July 18):
http://www.citizenshealthcare.gov/recommendations/interim_recommendations.php

HIGXYZ93HIGZYX The Group’s six interim recommendations are:

1. Guarantee financial protection against very high health care costs.
   No one in America should be impoverished by health care costs. Establish a national program (private or public) that ensures:
   
   
   
   • Coverage for all Americans,
     
   • Protection against very high out-of-pocket medical costs for everyone, and
     
   • Financial protection for low income individuals and families.
   
   
2. Support integrated community health networks.
   The federal government will lead a national initiative to develop and expand integrated public/private community networks of health care providers aimed at providing vulnerable populations, including low-income and uninsured people, and people living in rural and under-served areas, with a source of high quality coordinated health care by:
   
   
   
   • Identifying within the federal government the unit with specific responsibility for coordinating all federal efforts that support the health care safety net;
     
   • Establishing a public-private group at the national level that is responsible for advising the federal government on the nation’s health care safety net’s performance and funding streams, conducting research on safety net issues, and identifying and disseminating best practices on an ongoing basis;
     
   • Expanding and modifying the Federally Qualified Health Center concept to accommodate other community-based health centers and practices serving vulnerable populations; and
     
   • Providing federal support for the development of integrated community health networks to strengthen the health care infrastructure at the local level, with a focus on populations and localities where improved access to quality care is most needed.
   
   
3. Promote efforts to improve quality of care and efficiency.
   The federal government will expand and accelerate its use of the resources of its public programs for advancing the development and implementation of strategies to improve quality and efficiency while controlling costs across the entire health care system.
   
   
   
   • Using federally-funded health programs such as Medicare, Medicaid, Community Health Centers, TRICARE, and the Veterans’ Health Administration, the federal government will promote:
     
     
     
     • Integrated health care systems built around evidence-based best practices;
       
     • Health information technologies and electronic medical record systems with special emphasis on their implementation in teaching hospitals and clinics where medical residents are trained and who work with underserved and uninsured populations;
       
     • Reduction of fraud and waste in administration and clinical practice;
       
     • Consumer-usable information about health care services that includes information on prices, cost-sharing, quality and efficiency, and benefits; and
       
     • Health education, patient-provider communication, and patient--centered care, disease prevention and health promotion.
   
   
4. Fundamentally restructure the way that palliative care, hospice care and other end-of-life services are financed and provided, so that people living with advanced incurable conditions have increased access to these services in the environment they choose.
   Individuals nearing the end of life and their families need support from the health care system to understand their health care options, make their choices about care delivery known, and have those choices honored.




• Public and private payers should integrate evidence based science, expert consensus, and culturally sensitive end of life care models so that health services and community-based care can better deal with the clinical realities and actual needs of chronically and seriously ill patients of any age and their families.
  
• Public and private programs should support training for health professionals to emphasize proactive, individualized care planning and clear communication between providers, patients and their families.
  
• At the community level, funding should be made available for support services to assist individuals and families in accessing the kind of care they want for last days.


5. It should be public policy that all Americans have affordable health care.
   All Americans will have access to a set of core health care services. Financial assistance will be available to those who need it.
   Across every venue we explored, we heard a common message: Americans should have a health care system where everyone participates, regardless of their financial resources or health status, with benefits that are sufficiently comprehensive to provide access to appropriate, high-quality care without endangering individual or family financial security.
   
6. Define a ‘core’ benefit package for all Americans.
   Establish an independent non-partisan private-public group to identify and update recommendations for what would be covered under high-cost protection and core benefits.
   
   
   
   • Members will be appointed through a process defined in law that includes citizens representing a broad spectrum of the population including, but not limited to, patients, providers, and payers, and staffed by experts.
     
   • Identification of high cost and core benefits will be made through an independent, fair, transparent, and scientific process.
     
   • The set of core health services will go across the continuum of care throughout the lifespan.
     
   • Health care encompasses wellness, preventive services, primary care, acute care, prescription drugs, patient education, treatment and management of health problems provided across a full range of inpatient and outpatient settings.
     
     
     
     • Health is defined to include physical, mental, and dental health.
       
     • Core benefits will be specified by taking into account evidence-based science and expert consensus regarding the medical effectiveness of treatments.

Comparison of the public testimony with these recommendations reveals numerous areas where they reflect current administration policies more than the public’s input. For example, there was public consensus for ensuring that health costs not threaten "individual or family financial security." In the recommendations, the CHCWG supports protection against "very high health care costs," the approach promoted by the administration through high-deductible, catastrophic coverage. The administration’s proposal of tax credits to cover health care expenses was not supported by public participants who favored an equitable, progressively-funded insurance system covering everyone. Instead, the recommendations include the statement that "no specific health care financing mechanism is optimal."

There is a recommendation for "consumer-usable information about health care services that includes information on prices, cost-sharing, quality and efficiency, and benefits." This tenet of consumer-directed health care is actually contrary to the preponderance of public testimony favoring a system offering a comprehensive set of services. Nowhere in their recommendations do they acknowledge the strong desire expressed in their public hearings for national health insurance.

And their statement, "We understand that the transition from the current system to a system that includes all Americans will take time and that multiple financing sources will need to coexist during the move to universal coverage," is an expression of their bias for incremental improvements over more definitive ones. The initial release of the Interim Recommendations included a target date of 2012 for realization of a health care system for everyone. In spite of public support for a specific target date, the date was removed from the revised recommendations.

The two greatest deficiencies in the Group’s Interim Recommendations are its failure to address specifics with regard to methods of financing a comprehensive health care system, and ways of establishing the political policies to lead us there.