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Health care and governance: Big issues, practical responses.

New ideas for reforming health care are a staple of presidential election campaign promises as candidates grab for headlines and try to focus voters' attention on their proposals. The major health-care issues Americans face have remained the same since the early 1990s and, in fact, have deepened in scope. Chief among these issues is balancing care and costs, which are directly affected by changing populations and outmoded systems of health-care delivery.

A 2001 report by the Institute of Medicine states: "Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge," but quality problems everywhere affect many patients. The report concludes: "Between the health care we have and the care we could have lies not just a gap, but a chasm."

Today, double-digit inflation of health-care costs means higher premiums for employers and employees. It also means increases in Medicaid and Medicare state and federal health programs. Add to this growing populations of elderly, disabled and uninsured (now almost 45 million) because of the economy and job losses, and it's no wonder our health-care delivery system breaks down in quality and accountability.

Prescription medication prices and expensive new technology are steadily driving up health-care costs. At the same time, the aging of the baby boomers, higher numbers of disabled people (25 percent increase from 1999 to 2003), and an extended life span create groups that have specific health-care needs. These new dynamics place tremendous stress on Medicare and Medicaid.

Today, there are evidence-based treatments for those suffering from mental illness, but lack of insurance coverage keeps people who need care from having access to it. The cost for untreated depression alone is enormous and includes millions of dollars in lost workplace time, in "presentism" (being there, but not being productive) and in difficulties in parenting that have consequences for future generations.

Following are four avenues of change that can help improve the health-care situation immediately:

Disease Management. Medicare currently is experimenting with disease management for the elderly and disabled. Focusing on chronic illnesses and disease management through home care and community-based services could accomplish several goals, including lowering health-care costs and accommodating the diverse needs of baby boomers and the disabled.

Incremental Insurance Coverage. The number of uninsured people in America today presents a daunting challenge when taken as a whole, so it requires the response of a system as a whole. When specific populations of uninsured are identified, states can mandate health-care insurance targeted for these populations. For example, Massachusetts has mandated health insurance for the population of enrolled college students. The federal government also has instituted a partnership with states, called State Children's Health Insurance Programs, to cover thousands of eligible enrolled children.

Mental Health Parity. Better use of new psychotropic medicines, evidence-based therapies and community-based treatment can bring parity in mental-health care. Including mental-health care in employers' insurance policies will save companies money by preventing loss of labor and productivity.

New Technology. Effectively using cutting-edge technology to manage health care could both cut expenses and improve the quality of care. Technology makes information about costs and quality of hospital care available, for example, to consumers who can then make better personal health-care decisions.

And something as apparently simple as electronic health records for every patient can serve a variety of functions. Electronic health records, for instance, can: interconnect clinicians, foster collaboration and generate a national health information network; encourage consumers to maintain personal health records and promote telehealth in rural areas; unify public health surveillance architectures, streamline quality and health status monitoring; and accelerate the dissemination of evidence.

Very often, the big health-care issues that plague our nation are best met by practical responses that arise when one considers the art of the possible and courageously implements those ideas.

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