JAMA asks experts to examine 'critical issues' in health care

The Journal of the American Medical Association's current edition, published Tuesday, invited well-known health policy experts to comment on some of the big questions in their fields.

Journal of the American Medical Association: The Toxic Politics Of Health Care
It could be exciting. The ambitious nation that rallied to create the Marshall Plan, get to the moon first, and birth Medicare and Medicaid decides to move toward the health care it needs: universal, responsive, and affordable. But that task does not unite the nation; it rends it into political tatters. Health care reform could have been a moon shot, but instead it is a battlefield: red states against blue, north against south, coasts against the midland, and liberals, who trust in government, against conservatives, who don't. For me, this battle became personal (Dr. Donald M. Berwick, 11/12).

Journal of the American Medical Association: Toward A New Social Compact For Health Research
Over the past 10 years, US public investment in health research has been erratic. This recent pattern reverses decades of increasing support, initiated by the conviction and persuasiveness of visionary leaders such as Mary Lasker and Sidney Farber and realized through the continued commitment of legislative champions of biomedical science. Between 1999 and 2003, congressional appropriators doubled the budget of the National Institutes of Health (NIH) from about $15 billion to nearly $30 billion. The nominal budget then remained flat for the next 5 years, until the American Recovery and Reinvestment Act (ARRA) injected another $10 billion over 2 years, 2009-2010, a financial pulse that has since dissipated (Dr. Harvey V. Fineberg, 11/12).

Journal of the American Medical Association: Going To The Moon In Health Care
What is the simple, measurable, decades-long vision that will catalyze a transformation in US medicine? The answer today is unclear. Once the notion of universal coverage was medicine's [big hairy audacious goal]. It was clear and simple. It was long range. It was not assured though still attainable. However, it was transformative for the US polity but not really for the US health system. The Affordable Care Act may result in universal coverage, but that goal no longer has the qualities of a [big hairy audacious goal]. The US health care system needs a new [big hairy audacious goal]: ... by the end of the decade, health care costs per person will not grow faster than the economy as a whole (Dr. Ezekiel J. Emanuel, 11/12).

Journal of the American Medical Association: The Disruptive Innovation Of Price Transparency In Health Care
Until very recently, health care in the United States was delivered behind the secure walls of a fortress that kept information on the prices charged for health care and the quality of that care opaque from public view. Over time, enormous and ever-increasing amounts of money have disappeared behind the fortress walls. Much good undoubtedly was done for patients entering the castle in search of succor. But it has been nearly impossible for prospective patients thinking of entering the health care system to know what they or someone else will have to give up in return for whatever care they will receive from the inhabitants of the fortress (Uwe E. Reinhardt, 11/12).

Journal of the American Medical Association: Academic Health Centers And The Evolution Of The Health Care System
Today there are approximately 135 academic health centers (AHCs) in the United States. These institutions exist to ensure sustainable health care through their multifold, integrated missions of patient care, education, and research. Yet AHCs have in some ways contributed to the intractable problems that threaten both their viability and the sustainability of health care. To flourish-;indeed to survive-;AHCs must reconfigure and transform rapidly and broadly in size, speed, value, and innovation, driven by self-reflection and leadership (Drs. A. Eugene Washington, Molly J. Coye and David T. Feinberg, 11/12).

Journal of the American Medical Association: Unraveling The Physician Supply Dilemma
Over the past decade, physician shortages have worsened, patients' frustrations have increased, and the profession has molded itself around these new realities. Some forecasters project that the shortages will further deepen, and many organizations and individuals are urging that residency training programs be expanded. But others argue that additional physicians would simply work in places where there are enough already, that additional physicians would induce the demand for unneeded care, that fewer physicians would be necessary if more were primary care physicians, and that any gaps in service could be filled by nurse practitioners and physician assistants. Although desired by many, the expansion of residencies faces a wall of opposition (Dr. Richard A. Cooper, 11/12).

Journal of the American Medical Association: Resolving The Tension Between Population Health And Individual Health Care
Perhaps the de facto organizing principle for US health care-;approaching each patient strictly as an individual-;is obsolete. The population health approach is an alternative. It aims to improve and maintain health across a defined population. A "defined population" can mean a clinician's patients or a health plan's enrollees, but the defined population for the population health approach includes everyone in the community. This Viewpoint addresses 3 related questions. First, can the population health approach improve the outcomes of US health care? Second, for the population health approach to succeed, must it reconcile the needs of the individual and the community? Third, how might these needs become reconcilable? (Dr. Harold C. Sox, 11/12).

Journal of the American Medical Association: Reliable And Sustainable Comprehensive Care For Frail Elderly People
As the incidence of sudden and premature deaths has declined in the United States, the last part of most individuals' lives has come to be marked by progressive chronic illnesses and diminishing physical reserves that engender self-care disabilities and frailty. Those who live past age 65 years now average 3 years of self-care disability at the end of life, needing long-term services and supports (LTSS). For those living past 85 years old, nearly half will have serious cognitive decline. ... the United States needs arrangements that allow elderly people to live with confidence, comfort, and meaningfulness at a cost that families can afford and the nation can sustain. Failing to meet this predictable demographic change would force frail elderly people to live without critical services, effectively abandoned (Dr. Joanne Lynn, 11/12).

Journal of the American Medical Association: A Health Care Encounter Of The 21st Century
More patients are now living with multiple chronic conditions, but the health care system today is not equipped, nor has it evolved, to provide the integrated and coordinated care that meets the needs of patients of the 21st century (Dr. Denis A. Cortese, 11/12).

Journal of the American Medical Association: Consumers Gaining Ground In Health Care
At long last public and private initiatives are on the verge of giving consumers more information and more fair opportunities when it comes to obtaining health insurance and health care, reducing the uneven care and dysfunctional financing that have long plagued the health care system in the United States. The Affordable Care Act (ACA) is recasting the marketplace for health insurance, allowing consumers who shop on their own to make more informed choices among a better selection of health plans. Health insurers must now play by a different set of rules. Consumers with preexisting conditions are no longer denied insurance. The products for sale are more standardized, and important loopholes such as misleading out-of-pocket maximums have been closed (James A. Guest and Lynn Quincy, 11/12).

Journal of the American Medical Association: The Media And Health Care Reform
As implementation of the Affordable Care Act (ACA) moves ahead this fall, Americans remain startlingly uninformed about the landmark law and its prescriptions for the country's health care system. Fewer than 4 in 10 adults in a recent national survey were familiar with the new insurance marketplaces at the center of the law. In any democracy, public misunderstanding on this scale is troubling. Still more disturbing, this misunderstanding has helped paralyze policymaking at a critical point for the nation and its ailing health system. Ideological claims and counterclaims, often based on erroneous information, have displaced informed discussion about the trade-offs and compromises necessary in any major legislative reform. The uninformed public and policymaking paralysis are not the product of an information vacuum (Noam N. Levey, 11/12).