How Health Reform Would Have Changed History

Health-care reform is largely about everyday concerns—making sure more people are insured and have regular access to primary care to treat acute illnesses like the flu in proper settings, instead of emergency rooms, and helping to keep chronic illnesses such as diabetes in check. What it doesn't explicitly tackle is how the medical industry's response to unexpected public health crises and epidemics would differ. There's little in either the House or Senate bills that would result in more intense surveillance of outbreaks, for instance, and there's nothing in either bill that can prevent the criminal activity that led to two of the most alarming health stories of the past few decades—the Tylenol tampering scare and the anthrax attacks of 2001.

So, it's worth pondering if the current bills could have changed how some of the other big public-health crises of the past few decades would have played out: does having a more comprehensive health-care plan in place make a nation less prone to various epidemics and illnesses? We asked several experts to "run back the clock" (as one of them put it) and assess whether reform would have made any difference or saved any lives. Many of them agree that although it wouldn't have averted any crises, they may have been easier to bear. Here's a look at three health crises and how they may have fared under a comprehensive health-care-reform plan.

Could guaranteed health insurance have slowed the spread of AIDS?
Under both bills, health insurance companies will be barred from discriminating against people with preexisting conditions or rescinding people's insurance because of anything other than documented fraud. Both of those provisions could have made a tremendous difference in how AIDS was initially dealt with in the U.S., says Wendy Parmet, a professor of law at Northeastern University and a prominent lawyer who was co-counsel in the case that led the Supreme Court to apply the Americans with Disabilities Act to AIDS victims.

As HIV began to spread in the early '80s, so did fear. Many people worried (sometimes rightly) that they would lose their insurance if they were found to be HIV-positive—either because insurance companies would deem them a bad risk and drop them, or because they'd lose their jobs (and thus their insurance) if their status became known. As a consequence, some of them avoided testing, and were at more risk to passing the disease to partners unwittingly. 

Eventually, says Parmet, policymakers responded in a way that was "highly driven by the fact that people could lose their insurance"—they created a network of confidential testing centers, so people could find out their status without having it automatically reported to insurers. Those centers wouldn't have been necessary under health-care reform, since no one would have had to worry about losing his insurance or being unable to get any in the first place, and presumably more people would have gotten tested earlier in conventional settings.

The insurance dilemma created one silver lining for HIV/AIDS patients who couldn't afford treatment for their disease, either through insurance or out-of-pocket—they ended up getting the bulk of their AIDS care paid for by a different mechanism than the rest of their health care. (The act helps over 500,000 people a year with AIDS-related expenses.). AIDS advocates developed "a whole separate system of financing for HIV care" through the Ryan White Care Act, Parmet notes. Centers that received funding from the federal legislation became de facto hubs for treatment. This allowed institutions that applied for Ryan White funding to develop extraordinary expertise in treating the disease. It also gave AIDS advocates extra motivation to make sure their cause wasn't ignored, marginalized, or underfunded just because it was treated through a separate system. "If the funding had been more mainstream, if more of it had run through our typical health-insurance programs, would that specialization and skill have been lost? Maybe," says Parmet. "And the community mobilization around the disease might have been very, very different."

An interesting side note: Parmet says that many experts in the '80s believed the AIDS epidemic "might finally cause us to get universal health insurance, because private insurance at the time just couldn't deal with it." At least one book made the same case.

Could electronic health records have red-flagged the spread of SARS, bird flu, or the swine flu? What about West Nile?
Most would agree that America's system for identifying outbreaks early is in need of improvement. A recent report, issued by the health advocacy organization Trust for America's Health and the Robert Wood Johnson Foundation, found "serious underlying gaps in the nation's ability to respond to public health emergencies…[including] a lack of real-time coordinated disease surveillance and laboratory testing, outdated vaccine production capabilities, limited hospital surge capacity, and a shrinking public-health workforce."

And electronic medical records, as they're currently provided for in the health-care-reform bills, aren't likely to change much of that—and they wouldn't have helped experts track most of the exotic pathogens that have cropped up in the last few years.

In the case of West Nile, says Dr. Gerald Keusch, professor of international health and medicine at Boston University, the problem wasn't a lack of information about increases in illness and deaths. The information existed, and federal agencies had access to it. They just didn't know what to do with it. The CDC knew about rising cases of encephalitis in humans. It also knew about a Bronx Zoo veterinarian who was seeing similar fatal cases in birds. But it didn't investigate the link until months after it first came to light, and "by the time an effort was made to prevent [the] spread, by insecticide treatment to kill the mosquitoes, it was too late, and the infection was in the birds and silently spreading from the epicenter in New York."

As for the other pathogens—SARS, bird flu, swine flu—electronic medical records alone wouldn't have made much difference. That's because they're portable (meaning doctors and hospitals can share them with each other) but not searchable—there's no huge proposed database of everyone's medical data being updated in real time. "Electronic medical records alone, without a system to aggregate information to look for unusual trends, would have done nothing" to stop those diseases, says Keusch. To "pick out anomalous events," he says, you'd need "some algorithm-driven system accessing clinical information without identifiers other than perhaps age, gender, and geographic location."

It's technically possible to create such a system. But, says Keusch, "I fear there is insufficient trust of government or private sector groups like Google, with the capacity to do it, to give public endorsement for the effort." In other words, for most people, pathogens aren't the biggest concern—privacy is.

Could more comprehensive primary care have kept people alive during the 1995 Chicago heat wave?
More than 600 people died in 1995's infamous five-day heat wave, when temperatures topped out at 106 with a heat index (the warm-weather counterpart of wind chill) of 125. As soon as the mercury fell back to normal, doctors in Chicago started trying to figure out how they could have helped prevent so many deaths. Terry Vanden Hoek, who had just started as an attending physician in emergency medicine at the University of Chicago, was one of those doctors. . "There were a lot of questions about what we could have done better," he says. "The thing about heat waves is that they're pretty predictable. We knew this heat wave was coming. Yet we really didn't prepare for it as well as we could have." Neither did many of the city's elderly poor, who were afraid to go outside because of crime. They found themselves trapped in their own apartments and many died for lack of air conditioning.

Several provisions in the health-care-reform bills might have saved those people, says Vanden Hoek. The Senate bill calls for "community preventive services" grants—pilot programs that work to overcome health disparities rooted in poverty. Patient advocates and medical homes, or team-driven primary-care centers that coordinate all of a patient's medical needs, might have helped the Chicago doctors "keep track of who's elderly, who's by themselves, who's got diabetes and is especially vulnerable," says Vanden Hoek. "We could have called people and asked if they had air conditioners, or if they knew about the cooling centers we had set up. We could have arranged for transportation to get them out."

Still, a health system that pays special attention to tracking the poor and elderly wouldn't have managed to save everyone—at least if the European heat wave of 2003 is any indication. In France, even under comprehensive universal health care, almost 15,000 people died that summer from overheating. "You can have a very different health-care system [from what we currently have in the U.S.]," says Vanden Hoek, "and still be unprepared for this kind of emergency."