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Steven Schroeder--Interview Notes
HC2020 Interview Summary—Steve Schroeder
1. His/her work—Interested in health policy particularly in temrs of care and access. He currently heads a Smoking Cessation Program at UCSF and plays around doing work for the IOM and various other organizations.
TRENDS/CHALLENGES
2. How optimistic about future of health/healthcare in 2020?
He would separate health and health care—he’s optimistic about health in the sense that smoking rates are continuing to decline, driving deaths are down, obesity rates (he believes) may be peaking, and social attitudes are generally orienting toward healthy living. On the other hand, he is pessimistic about health care and believes that ongoing problems in terms of cost and access will continue for the foreseeable future barring a much larger economic recession than our current recession. “So, I am confused” he said, “But we damn well better get a handle on costs or health care is going to cannibalize” everything else.
3-4. Biggest trends or challenges & responses
1) Physician training/specialty mix. Increasing specialization of medicine is eroding access to primary care, increasing costs, and in terms of “the values of how physicians get reimbursed for fee for service” the decline in primary care/physician specialty mix is eroding health care.
2) Diagnostic/Therapeutics: Innovations here are going to be very expensive and “people will want someone else to pay.” For example, new genetic tests, as well as biological diagnostics will be very costly, as will targeted cancer therapies and the like. “We may get increasingly very sophisticated, but there won’t be volume, so it’s going to be extremely costly.”
3) Cultural attitudes/opinions about health and wellness are trending positively (see above.)
4) Class drives a lot of inequality and unequal outcomes, and the response to this may be scapegoating by the middle and upper classes, since expanding access would necessarily (or likely) erode access of wealthier individuals. This is a driver in terms of our bad health outcomes, but he doesn’t seem this driving anything positive. Gradations tend to be stepwise with the biggest break/difference coming around the 50% mark.
5. Have these trends surfaced before?
See above: challenges in health spending are persistent, somewhat accelerating, as is the issue involving the physician/specialty mix. He cited MADD and other organiztions in terms of an approach to health and wellness, saying that “government is a trailer” and advocacy groups are leaders. In other words, on the health (separate from health care) front, look for bottom up/attitudinal shifts and other similar approaches.
6. Challenges/responses not on radar now?
Class- Again, see above: But most health research into inequalities tends to focus on other variables, but he argues that class is more important than many of those and is a meaningfully relevant feature.
Shifting population demographics: “We are a nation of young immigrants” and it’s not entirely clear that our delivery system in terms of hospitals and caregivers is really set up to facilitate caring for them.
FUTURE SCENARIOS
7. Most preferable scenario
Care would move upstream to encouraging health and away from high tech medical care and end of life care. He’d like a “health impact statement” appended to changes in public policy and thinks that health should become a more critical part of political calculus. In terms of health care, people would recognize that spending is finite, embrace solidarity, and recognize that people who want expensive stuff with little chance of success should have to pay for it. This is not terribly likely, in his opinion.
8. Most plausible scenario
We keep muddling through but we may mess around on the edges by slowing growth rates slightly, slightly cutting the rates of the uninsured, etc. This would likely include a widening gap between the haves and have notes—gains in health status would continue to accumulate among the upper half of the country, with them doing better and better and lower classes stagnating or getting worse.
9. Most negative scenario
We treat health care as a market good and ration by price for the poor. We cut costs on the back of Medicaid, “which is basically what the states are doing now.” Policymakers look to electronic records and other innovations which don’t address underlying problems. “We tend to look to painless technical solutions to fundamentally social and political issues.” As a result, inequality flourishes. The haves band together to preserve access to all the good stuff and leave it to the charitable and public sectors to care of the less fortunate (the charitable sector which has been starved due to lower taxes and fewer donations.) This is not unlikely.
10. Wrap-up
Check out the following:
“Class: The Hidden Determinant of Health Care”
Tom Bodenheimer, Mitch Katz, Nancy Keugler, Andy Stern (i.e., labor.)
Emphasized that we should be sensitive to giving too much weight to the extent to which technological shifts can affect change “you overinflate the technologies and underinflate the politics.”