Dr. Robert Gold’s Perspective

Dr. Robert Gold is the Dean of the School of Public Health at the University of Maryland, College Park. Dr. Gold worked at the Office of Disease Prevention and Health Promotion within the U.S. Department of Health and Human Services. Over the past three decades, he has been a leader in issues of health promotion and disease prevention, health equity and the use of advanced communications and computing technology in health.

Below are five of the most important health care reform considerations advanced by Dr. Gold for this round of health care reform, with special consideration of meeting the needs of vulnerable populations and the use of emerging science and technology.

1) The U.S. Health System Must Be Reorganized Around Maximizing Health Status

Many of the drivers of health care over the past half century have not been pointedly focused on improving the health of Americans. Market dynamics have, in many ways, made American medicine one of the most profitable sectors in the American economic system. Its profitability has driven significant innovation, but it has also created huge health status disparities that current U.S. public and private approaches to health insurance have not sufficiently addressed. The U.S. Health System has to be reoriented toward maximizing health status indicators with an emphasis on improving health status in the most vulnerable populations. This will require a health system reform initiative that extends well beyond the traditional medical care insurance reform.

2) The 21st Century U.S. Health System Must Provide Broad-based Solutions Upstream

The American public must have access to good quality medical care. However, we can no longer spend well over 90% of our health care resources on after-the-fact disease care, when lifestyle and environmental factors constitute 70% of the overall determinants of health. The U.S. needs a health system that addresses the true determinants of health, before the cost and pain of invasive therapies are needed.

In losing focus on the goal of optimizing health status for all Americans, we are now spending 30% of our health care dollars in the last year of life, while large numbers of American children are now being born with little to no prenatal care. This has caused U.S. maternal mortality and newborn mortality to rise to levels worse than Cuba and that of other significantly less developed nations. Our nation now routinely spends tens of thousands of dollars (not infrequently, hundreds of thousands) on medical procedures per individual, for conditions that could have been prevented at a cost of hundreds or thousands of dollars, especially in association with chronic disease (e.g., diabetes, cardiovascular disease) in which the key determinants of health outcome are lifestyle or modifiable environmental factors.

There is now an opportunity to measure the socio-ecological determinants of health at the community level with significant specificity. Health disparities can be scientifically visualized down to the neighborhood level. The most efficient way for the U.S. to improve its health status indicators is to direct its health sector resources (financial, human resources, and knowledge assets) in the form of policies and programs toward relieving health disparities in the most vulnerable communities that are most at risk for poor health status.

3) Improving Population-based Determinants of Health

Population-based determinants of health may be more easily and more cost effectively impacted by community interventions outside of the hospital and clinic. For example, in neighborhoods that have a large number of liquor stores, but no local access to fresh fruits and vegetables, policies affecting access to fresh foods may be far more important to health status in that community than having a hospital within its jurisdiction. In neighborhoods where violence is correlated with the sale of alcohol, more stringent control of alcohol along with other alcohol-free venues for recreation and entertainment may be key to health status in that area.

Ultimately, health equity is dependent upon a balance of many factors, such as access to care, access to a broad set of health-enhancing products of services, and access to non-biased health information. Health literacy and economic factors, for example, also play a crucial role on population health in many under-privileged communities which, if appropriately addressed, may result in benefits from improvements in employment opportunities, public works, transportation, and other infrastructures as part of a broader-based health system transformation.

4) The Role of the Web and Information Technologies in Health System Transformation

The majority of Americans now have access to the World Wide Web. One of the most prominent uses of the Web is for health information and decision support. The quality of health decision support on the web can be expected to improve significantly over the next ten years with appropriate funding toward research, applications, and education regarding the utility of these new network-based health service options.

During the past ten years, Americans have witnessed a huge growth in online health services. There has been significant emphasis on the importance of the Electronic Medical Record. However, ubiquitous access to more generalized personal health records may have far more impact on health than the clinical record alone.

The ideal would be to have a nation-wide network of interoperable health information systems including health management systems with proactive consumer-based Personal Health Records linked to physician-based Electronic Health Records allowing for facile physician-prosumer (proactive consumer) communication well integrated into community-oriented primary care. The interoperable health information systems at the community level would then be linked at the regional, state, and national levels to compose a U.S. wide interoperable public health information infrastructure. In this model, RHIOs (Regional Health Information Organizations) would then provide a foundation for private and secure sharing of population and personal health data. as well as enable the integration of personal health, clinical information, and public health applications and decision support,.

5) All Policies at the International, National, State, and Local Levels Affect Health

In today’s interconnected world, citizens, policy makers and diplomats have to recognize that all policies affect health. For example, even moneys spent on defense, environment, energy, and transportation can be designed to optimize health outcomes, or ignore health impacts at the peril of our citizens’ health and well-being. True health system transformation would engage a revolution in management and governance, similar to what is being proposed in the National Sustainable Security Infrastructure and the U.S. Resilience System to move toward a deeper understanding of the socio-ecological foundations of health and disease. U.S. domestic and international policy should be shaped to consider and optimize the health of Americans in conjunction with improving global health.