The best news about the health care legislation now on the brink of congressional approval is that the United States will be making an historic move toward providing care for all Americans at reasonable costs. Some 30 million more Americans will be covered–moving us, finally, toward the universal coverage standards long observed by all other industrialized democracies.

But–when President Obama signs the legislation, this will be a Christmas present very much in need of assembling. The added millions of insurance recipients will provide one of the most daunting management and public administration challenges we’ve ever faced. This is bigger than welfare reform, education reform, even homeland security.

Why? Topping the list, in my judgment, is changing the Medicaid system which is now the largest insurer in our nation. It provides–in combination with the Children’s Health Insurance Program (CHIP)–coverage to 60 million Americans. The Congressional Budget Office projects that 11 million of the newly insured Americans will become enrolled in Medicaid by 2019. Estimates are that, through this reform, approximately 25 percent of the entire U.S. population will be enrolled in Medicaid for at least some of 2019. What was originally conceived as a “welfare” program for the poor will be transformed into a mainstream health insurance program, without stigma and, hopefully, with credibility for providing access to quality care that is affordable.

But getting there from here will require overcoming major obstacles. For starters, today only about half of this nation’s physicians even accept new Medicaid patients. Stigma, low payment rates and slow payment procedures are part of this problem. Given our nation’s pattern of residential segregation based on income and race, most Medicaid recipients live in medically underserved communities where there are simply too few health care providers to assure timely, quality care. The health care workforce will have to be increased and be diversified. This should be good news for many local economies.

If the final bill does expand Medicaid eligibility to 133 percent or 150 percent of the federal poverty level by 2013 as projected, there is still a window of time to begin to address these pressing workforce issues before millions more uninsured adults (without children), and low income working families will need to be enrolled in this state/federally financed program.

There is, of course, something inherently right about expanding Medicaid. It is our nation’s most compassionate insurer, having evolved now to cover not only vulnerable low income mothers and children, but the blind, aged and persons with disabilities, as well as those who experience disasters, like hurricanes, or temporary unemployment. It also pays for health care for those whose incomes and medical conditions combine to necessitate long term care.

But–some Medicaid directors are already panicked by the very thought of the pending enrollment expansion. And for good reason. States have faced a decade of budget constraints and, most recently, dramatic recession-generated deficits. Although some relief came this year from the re-authorization of the CHIP in 2009 and from funds in the American Recovery and Reinvestment Act, this fiscal relief is scheduled to wane in 2010, leaving many states’ Medicaid budgets facing serious shortfalls.

Already, states such as Massachusetts and California are on life support when it comes to meeting escalating health care needs for low income families in the face of declining revenues. Cash strapped state Medicaid budgets translate into reduced services for vulnerable families. Mental health care, coverage for some prescription medications and dental health care access are often sacrificed.

All this means Congress will have to assure long term, robust federal support for the proposed Medicaid expansion. And even then, implementation will require applying critical lessons about government reinvention from past, sometimes unrelated efforts at transforming our public systems.

Here are some of the lessons we should have learned, and will now need to apply:

• Allow ample time for planning and designing regulations and assure early citizen engagement that reflects the income and diversity of the communities that will be affected by the reform.
• Identify and remove bureaucratic obstacles to creating the required technical and human infrastructure for effective program implementation. This may mean streamlining procurement and hiring processes.
• Use contemporary tools of engagement, such as social media and marketing to manage perceptions and expectations of the process and to provide timely feedback.
• Provide incentives for innovative approaches to outreach, management and performance improvement. Disseminate news about new strategies and support innovators.
• Build in the capacity for real time monitoring, data analysis and integration, to enable data-driven decisions and responses.

Bottom line: the new legislation’s breakthrough era for health care access in America will require unprecedented collaboration involving government, nonprofit and private agencies. Rough spots are surely ahead. But, like proud parents on Christmas morning, we, as a nation must be up to the task of putting this “present” together and witnessing the joy of those that will most assuredly benefit.

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Over 80 percent of Americans, according to a recent Time magazine poll, say they’re “satisfied” with their health care plans. But as the discussion escalates and special interest groups struggle over health care system reform that broadens insurance coverage, we’re missing the voices of a major population segment. Check with Americans of color and a disturbing picture emerges: they’re receiving less effective health care, experiencing worse health outcomes, than the population at large.

We know from repeated surveys that our minorities–African Americans, Hispanic/Latinos, American Indians and Alaska Natives, Asian Americans, Native Hawaiians and Pacific Islanders–experience higher rates of infant mortality, cardiovascular disease, diabetes, HIV Infection/AIDS and cancer than Americans in general. They also face higher rates of disability, chronic disease and premature death.

Why? The picture is explained by inadequate access to health care, and in some well-documented instances, inferior or poor quality care. But check further and you find inequities attributable to limited access to opportunity, chronic subjection to racial discrimination, limited educational achievement, barriers to living wage employment, and isolation in neighborhoods of concentrated poverty. Unsafe housing and vviolence-afflicted neighborhoods explain generational cycles of chronic disease and premature death more fully than access to medial care alone.

If the country is to reform its health care significantly, it’s can’t stop with issues of improved efficiency, affordability and insurance coverage. Demography is destiny and we know that our population is rapidly becoming more diverse, that minorities’ population growth significantly exceeds that of whites. We can’t improve America’s health without improving minority group health; achieving health equity will require more than reformed health care insurance.

Indeed, the underlying premise of the Department of Health and Human Services’ “Healthy people 2010 Agenda” is that the health of a person is inseparable from the health of the larger community. Delores Acevedo-Garcia and her colleagues at Harvard’s School of Public Health have developed a data system, Diversity Data, that compiles overwhelming evidence demonstrating correlations between residential segregation by race and many poor health outcomes, including infant mortality and childhood obesity.

Some fear that broadening the current health care debate to include health equity just makes a daunting challenge all the more difficult. Yet there’s a harsh fact: the United States is not just a global laggard among advanced nations in offering universal health care access; it also lags behind many on the fronts of health equity and addressing the social determinants of health.

Responding to the World Health Organization Commission on Social Determinants of Health, the European Union has recently moved to design and implement a multi-year approach to the issue. Its title, significantly, is DETERMINE, with an on-line resource, the European Health Portal for Action on Health Equity. In addition to the EU efforts, Brazil, Chili, Canada, Iran, Kenya, Mozambique, Sri Lanka, Sweden and the United Kingdom have all become partners with the World Health Organization (WHO) in affirming their countries’ commitment to make progress on health equity and the social determinants of health.

Many public health advocates in the United States have worked tirelessly to insert prevention and community health initiatives into the current health care reform legislation proposals. Their efforts are to be commended. But it is time for the United States to partner seriously with other world nations to focus on health equity issues. Michael Marmot, WHO Commission Chair, reminds us correctly:

“Central to the Commission’s recommendations is creating conditions for people to be empowered to have the freedom to lead flourishing lives…. We rely too much on medical interventions as a way of increasing life expectancy. A more effective way of increasing life expectancy and improving health would be for every government policy and program to be assessed for its impact on health and health equity, to make health equity a marker for over all government performance.”

That’s the central lesson. And it makes all the more difference for the United States, because we know that in less than two decades, the majority of children in this country will be children of color. In their provocative 2002 book, The Miner’s Canary, Harvard Law Professors Lani Guinier and Gerald Torres show how issues of race aren’t just a case of equity for its own sake, but also point to conditions in American society that endanger us all. Nowhere is this metaphor more salient than in the health reform debate. We must see health disparities as the canary in the mine, recognizing the danger that we all face if we do not work for health equity and address, with fresh vigor, the social determinants of health.

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Health care reformers are celebrating the fact that both presidential candidates listen to the poll data and promise, if elected, to fix the issue of peoples’ access to health care coverage.

The Republican and Democratic plans have clear differences. But they’re together on one point: they only address access to formalized health care — the doctor-hospital-prescription-medical side. Neither party’s plan recognizes mounting, compelling evidence that the most effective strategies to further peoples’ health are common sense measures we as a nation could undertake.

What are those measures? They’re hidden in plain sight. They include making neighborhoods safer, streets more walkable, and reducing contaminants so that we can have more safely breathable indoor and outdoor air.

A huge factor is good nutrition — local food systems that provide equitable access to the required fruits and vegetables for disease prevention. And then steps to reduce adults’ and children’s exposure to violence — whether it’s real or popularized/legitimized in popular media.

It’s easy to say personal behaviors, like not smoking or eating sensibly to avoid obesity, are a key. And in some respects, they are. But there’s a grim fact: collectively, as a society, we’re paying a gruesome cost for a treatment-after-the-fact health culture.

We spent a mind-numbing $2.1 trillion on health care in 2006. That’s 16.2 percent of our Gross Domestic Product. It’s projected to reach $4.1 trillion, or 19.6 percent of GDP by 2016. That’s a huge toll on our national economy and well-being. This is a critically important issue for all of us, as a society.

Indeed, such experts as the noted public health authority J. Michael McGinnis estimate that if one adds up all the factors that contribute to health, only 10 to 15 percent of preventable deaths in the United States could be avoided by better availability or quality of health care.

How backwards can we be, to spend all our money on the medical model, potentially bankrupting our country, and still come out with all these the poor outcomes we see today!

Let’s face the reality: America could finally enact universal, single-payer, health care reform, and yet continue to perform abysmally in comparison to other developed nations in health status indicators such as infant mortality, life expectancy, death and debilitation from diabetes and other chronic degenerative diseases. And we’d still be “leading” the world in per person health care dollar outlays.

So let’s stop blinking at realities. A top example: poverty is fast emerging as the leading predictor of lifelong health status. Yet more than 13 million children lived below the federal poverty line in 2006 — 5 million in extreme poverty. Eleven states have child poverty rates of over 20 percent. Many urban school systems graduate less than 25 percent of the children who enroll in high school.

On top of all that, racially-based discrimination abounds in housing, job opportunities, and law enforcement practices. These factors help to perpetuate racial disparities in disease and health outcomes. Black babies die at two to three times the rate of white babies during their first year of life in America. And men of color still have the lowest life expectancies.

It’s heartening to note that some 15 states have recently set up bipartisan commissions to see how to narrow the yawning income gaps that leave so many Americans in destitution.

But we need national leadership to inspire action across all states and communities. The next president needs to marshall the resources of his entire Cabinet and engage all government agencies in creating a health agenda for America.

David Walker, former director of the Government Accountability Office, continues to sound the alarm about runaway entitlement expenditures, reminding us that Medicare and Medicaid will overwhelm all other domestic spending if current trends continue. But Walker’s proposed solutions are limited to a financial paradigm.

The real solution to the approaching the medical care, cost-driven fiscal crisis is on the demand side of the equation. Perhaps the solution lies in engaging our nation in “creating health” instead of just “fighting disease.”

What if the next president were not only to talk up health and physical fitness but move aggressively toward a “post-medicalized” America by appointing a health adviser, a person charged with monitoring and encouraging health-promoting activities across the government, reporting directly to the president?

Such a White House officer could keep his or her finger on each relevant agency — not just Health and Human Services but Labor, Housing and Urban Development, Commerce, Transportation, Environment, Education, Defense, and Treasury. Each would be held accountable for promoting health in all its operations, including rule-setting that impacts, states and local communities.

This type of coordinated, focused, visionary leadership would mean real change for America. The benefits, physical and fiscal alike, would be almost too great to measure.

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