Nevada health leader believes reform will pass Congress

There is no more distinguished physician in the United States than Mary Guinan.

She spent much of her early career working on the historic mission to eradicate smallpox. (Victory was declared in 1977, though there have been signs of a resurgence.) She served 20 years with the Centers for Disease Control and was on a renowned early AIDS research team. Now dean of the University of Nevada, Las Vegas, School of Community Health Sciences, she also served until recently as Nevada Health Officer, during which she dealt with childhood leukemia in Churchill County, the Las Vegas hepatitis scandal and the swine flu. (In the 1993 motion picture And the Band Played On, Guinan was portrayed by actress Glenne Headly.)

For a health care professional and a student of health policy, these are not days of pleasure and contentment. The national debate over health care falls several miles short of being the exercise in democratic enlightenment it could have been.

But Guinan also calls herself a “perpetual optimist,” and she is sure that reform—if not of health care, then of health insurance—will emerge. One bit of evidence she cites is the wrath of the opposition.

“I believe that the ferocity of the attacks by the opposition to health-care reform indicates that the proponents are very strong,” she said. “So they have brought out their weapons of mass destruction. But I don’t think they will be effective.”

She said that what Congress is debating isn’t actually health-care reform.

“It’s health-insurance reform, and we certainly need that, but we also need very badly to develop a system of health care, which we don’t have.”

But if that health-insurance reform is enacted by Congress, she believes, it would likely lead to health reforms, including “a systems approach” to health care in which components work together.

Talk of a bureaucratic federal system, she said, overlooks the already bureaucratic private system—“Much of the health care provider’s time is taken up in insurance and forms.” To say nothing of the patient’s.

Guinan said that while many people fear federal intrusion in health care, an enhanced federal role will probably be very helpful in Nevada, where the health care system is primitive. The state’s system, in her view, is as much threat as aid to the public. In Nevada, she said, important components of the system do not communicate well, or at all, with the result that patients could actually see their conditions become worse or die. By law or by practice, information is not passed between agencies.

At an endoscopy facility in Las Vegas, for instance, there were unsafe practices going on in a clinic, and some groups were aware of it while others were in the dark.

“They had had their license pulled some months before by the ambulatory care association and because it’s a private licensing group, they did not—it’s confidential—and so that the ambulatory care facility did not report it to the state. Well, that was a big problem for us,” Guinan said.

She says that while health programs are and will continue to be operated by the states, the federal government will be able to enforce standard communications procedures on the states of the kind that Nevada has lacked.

She said Nevada is one of the states that stands to benefit most from health-care changes, because the state currently does so little to aid the uninsured. The other side of that coin is that if Congress does nothing, Nevada will suffer more than most states.

“Well, I think that we’ll be, honestly, doing the same thing that we do now,” she said. “And we don’t cover a large segment of our population. And I’m sure you’ve seen the stories of so many people who—their insurance doesn’t cover their—whether it’s treatment for cancer or other chronic diseases or they can’t afford health care. … The data say one in five Nevadans are without health insurance. I believe it’s much higher. I would say that we have almost 30 percent, I would guess, that are either under-insured or uninsured. And we have no plan. We have no plan to help them.”

“Our Medicaid coverage is a partnership with the federal government. The federal government pays [for some of it]. The state contributes part. And the state determines what level of coverage, you know, what level of poverty will be covered by Medicaid. So it depends. And ours [in Nevada] is really minimum. We really don’t cover the working poor.” (Medicaid is a means-tested health care program for low-income people jointly funded by the state and federal governments and administered by the state governments.)

Medicaid care, she said, is preventive and thus cost-effective—it prevents early problems from developing into major and very expensive problems.

On Monday this week, a new Harvard study reported that an estimated 45,000 people in the United States die every year—one every 12 minutes—because they lack health-insurance coverage.

There was no state-by-state breakdown, but if it followed Nevada’s share of the national population (0.9155), then the state would lose 411 people annually. Given Nevada’s low placement on national rankings on quality of life indicators, the state may well be doing even worse than that.

Guinan said predictions that Nevada—and particularly rural Nevada—will lose some of its hospitals if health care changes are not made by Congress are probably sound (“What if?” RN&R, Sept. 17).

“Well, I think that probably is accurate that our hospitals are going to be in deep trouble because that’s where [low-income] people go when they’re sick, is the emergency rooms. Emergency rooms are clogged up now. We know how much they are problems and how much money is lost. I mean, we only have one hospital in the state that really is a public hospital, which is University Medical Center [in Clark County], and they are in a continuing crisis.”

Guinan is not impressed by non-public alternatives that are supposed to solve the health care crisis if the Democratic plan is defeated.

“[W]hy haven’t they done it?” she asked about the insurance companies. “This has been a mess for 20 or more years, and it just has gotten worse and worse: Fewer and fewer people qualifying, higher and higher rates, more and more money spent, trillions of dollars, and our health care isn’t any better except for, you know, the exceptional few who get the best health care.”

A federal role could also lead to better information on fundamental issues, Guinan said. She said private hospitals claim huge amounts of indigent care they’ve donated, but there are suspicions that they’ve cooked the books.

“If you don’t have health insurance you’re charged much more than if you do have health insurance because all health insurance gets a discount. … So you see, if they say, ‘Oh, we’ve given all of this health care for this large amount of people,’ they use a [higher] rate that is different from the rate that they charge [the insured].”

Another benefit to a federal role, Guinan believes, will be that it will help break up sweetheart relationships among health care players.

“[T]he … health insurance and the pharmaceutical industry are usually hand in hand in not changing the system because they have a vested interest in keeping things the way they are because they’re quite profitable. We somehow have to break that dependence between the pharmaceutical companies and insurance companies.”

So how do those cozy relationships increase health care costs?

“The insurance companies—many in Nevada—don’t cover administration of vaccinations for children, so that the children go to the health department to get their vaccinations. Well, public health agencies have a contract with the pharmaceutical companies for large doses of vaccines so they get a big discount [on bulk purchases]. And the pharmaceutical companies don’t make money on that, so they want the insurance companies to cover it—immunizations—so they can get maximum dollar.”

If the insurance companies go along, it will drive up the cost of immunizations.

After failing to react for many weeks, some news organizations finally began correcting the myths and lies being spread about health care proposals. These links can lead to some of the best articles or features that sort out the facts from the lies.

• www.lasvegassun.com/news/2009/sep/13/separating-reform-fact-fiction/

• http://blogs.harvardbusiness.org:80/haque/2009/08/how_to_think_constructively_ab.html

• www.washingtonpost.com/wp-dyn/content/article/2009/08/21/AR2009082101778.html

• http://www.politifact.com/truth-o-meter/