Uwe Reinhardt: Remembering a Titan of U.S. Healthcare Policy, at an Inflection Point in the Shift Towards Value
On August 8, a team of healthcare policy researchers published a tribute to Professor Uwe Reinhardt, Ph.D., of Princeton University in the Health Affairs Blog, entitled “Who Will be Our Moral Conscience Now? A Tribute To Uwe Reinhardt.” All four—Janet Currie, Katherine Ho, B. Rose Kelly, and Ilyana Kuziemko—were colleagues of Reinhardt’s at Princeton, and had gathered with other colleagues last spring to honor Reinhardt and to discuss what’s next in U.S. healthcare policy.
As the authors write in their Health Affairs Blog piece, “It has been more than a year since the passing of Uwe Reinhardt, a giant in the field of health policy. His voice was listened to. Now that he is gone, many academics, ourselves included, grapple with the question of how we can make sure his ideas continue to be heard. A number of academics and health policy practitioners gathered this past spring at Princeton University for a conference on “Insights on Health Policy” to honor Uwe’s legacy and discuss what’s next for health policy in the United States. We compared the US to other countries and discussed the role of prices in health spending, the feasibility of further major health care reform in the US, and the importance of providing health insurance for all. In true Uwe fashion, we also discussed, at length, our moral obligation to insure access to health care for all. “
Further, the authors write, “We attempted to ask big questions, as Uwe challenged us to do. As academics, and health economists, our work is nuanced and often focused on relatively narrow issues in health care. Ever the teacher, Uwe would remind us not to forget the big picture. We debated the evidence, challenged each other’s theories, and in many cases, did so with a laugh. We found that our conversations often mirrored Uwe’s thoughts on the system in his last book, Priced Out: The Economic and Ethical Costs of American Health Care.
And, they note, “A quick-witted scholar, Uwe was cognizant of and appreciative of evidence. At the same time, he understood that data cannot provide the last word on policy when important values are at stake. He enjoyed calling “foul” when confronted with poor logic and often did so in a funny, relatable way. Following the data, keeping our values firmly in mind, insisting on rigor, but proceeding with courtesy and good humor—these are all lessons Uwe taught. At the end of the day, everyone agrees there is no magic bullet and that, in the US, further health care reforms face many roadblocks. Our political climate, especially as we head into the 2020 election, plays a powerful role,” they add.
The Princetonians’ tribute to Dr. Reinhardt is well-placed. Uwe Reinhardt was a giant among U.S. healthcare leaders, for a variety of reasons. First, he was among the very few healthcare economists who regularly ventured outside the cloistered halls of academia to address real-world issues in real-world conferences; the vast, vast, vast majority of economists rarely appear publicly, and if they do so, it is almost inevitably solely at academic conferences with fellow scholars, where they discuss the minutiae of theory and argue over those proverbial angels dancing on the head of a pin. That was the opposite of what Uwe Reinhardt did; he absolutely loved mixing it up on panels with discussants from across healthcare.
Not only did Uwe Reinhardt have a rapier wit, which he loved to use in order to get reactions from his audiences; he also saw the big picture. It was he who, as far back as the 1980s, warned of the ginormous cost cliff our country is about to go over now. Indeed, one of the things that he did at nearly every appearance, and which inevitably elicited guffaws and little gasps and yelps from the audience, was to show his favorite fever chart, which tracked U.S. healthcare system costs until they reached 100 percent of GDP (gross domestic product). He got a guaranteed laugh whenever he presented that fever chart. But then he would immediately point out that every tiny uptick in percentage of GPD spent on healthcare was crowding out potential spending on other important policy needs—education, transportation, infrastructure-building, etc., etc.—and he would talk about the irresponsibility of allowing the fee-for-service healthcare system to continue down a track towards ruin.
In an obituary published in The New York Times on November 15, 2017, two days after his death, Sam Roberts wrote that “Professor Reinhardt helped shape health care deliberations for decades as a prolific contributor to numerous publications, an adviser to White House and congressional policymakers, a member of federal and professional commissions and a consultant and board member, paid and unpaid, for private industry.” And, he noted, “With near unanimity, colleagues and admirers praised Professor Reinhardt for transforming raw data into moral imperatives.”
Roberts also quoted Professor Currie, the lead author of the Health Affairs Blog article, as stating that “His work was instrumental in advocating some of the reforms embodied in the Affordable Care Act, such as having Medicare pay for performance rather than entirely on a fee-for-service basis.”
Another colleague, Stuart H. Altman, a professor at Brandeis University, wrote of Professor Reinhardt that “No one was close to him in terms of impact on how we should think about how a decent health care system should operate.” Furthermore as Roberts noted in the Times obit, “In 2015, the Republic of China awarded Professor Reinhardt its Presidential Prize for having devised Taiwan’s single-payer National Health Insurance program. The system now provides virtually the entire population with common benefits and costs 6.6 percent of the nation’s gross domestic product (about one-third the share that the United States spends).” And, Roberts noted, “Professor Reinhardt argued that what drove up the singularly high cost of health care in the United States was not the country’s aging population or a surplus of physicians or even Americans’ self-indulgent visits to doctors and hospitals. ‘I’m just an immigrant, so maybe I am missing something about the curious American health care system,” he would often say, recalling his childhood in Germany and flight to Canada and apologizing that English was only his second language. Then he would succinctly answer the cost question by quoting the title of an article he wrote with several colleagues in 2003 for the journal Health Affairs: ‘It’s the Prices, Stupid.’ What propelled those prices most, he said, was a chaotic market that operates ‘behind a veil of secrecy.’ That market, he said, is one in which employers ‘become the sloppiest purchasers of health care anywhere in the world,” as he wrote in the Economix blog in The New York Times in 2013.”
As the Amazon description of his last book, completed and published posthumously by a team of colleagues, notes, “Uwe Reinhardt was a towering figure and moral conscience of health care policy in the United States and beyond. Famously bipartisan, he advised presidents and Congress on health reform and originated central features of the Affordable Care Act. In Priced Out, Reinhardt offers an engaging and enlightening account of today's U.S. health care system, explaining why it costs so much more and delivers so much less than the systems of every other advanced country, why this situation is morally indefensible, and how we might improve it.”
Further, the description states, “The problem, Reinhardt says, is not one of economics but of social ethics. There is no American political consensus on a fundamental question other countries settled long ago: to what extent should we be our brothers' and sisters' keepers when it comes to health care? Drawing on the best evidence, he guides readers through the chaotic, secretive, and inefficient way America finances health care, and he offers a penetrating ethical analysis of recent reform proposals. At this point, he argues, the United States appears to have three stark choices: the government can make the rich help pay for the health care of the poor, ration care by income, or control costs. Reinhardt proposes an alternative path: that by age 26 all Americans must choose either to join an insurance arrangement with community-rated premiums, or take a chance on being uninsured or relying on a health insurance market that charges premiums based on health status.”
Endeavoring to continue the important discussion that Dr. Reinhardt was so much a part of for decades, his Princeton colleagues note in their blog that “In his lifetime, Uwe experienced health care in three countries: First, as a boy growing up in post-war Germany, then as teenage immigrant in Montreal, Canada, after fleeing Germany, and finally as an American. Each of these systems played a profound role in shaping Uwe’s thinking on health economics and helped carve out his career path. At our conference,” they write, “ we heard about health care in Taiwan, Germany, Canada, and Switzerland. The United States has the weakest performance in terms of access, expenditures, and health outcomes. How have we gotten to this point? We agreed that a major discussion of societal values has been missing from health care debates. Do we, as a country, really want health care for all?”
Coming up to the point of the present moment, the authors write, “As the idea of Medicare for All gains popularity, it is important to look at a range of systems, which we did at our conference. John Iglehart, founding editor and former editor-in-chief of Health Affairs noted that a single-payer approach, such as that seen in Canada or Taiwan, is just one way to achieve universal health care coverage. Multipayer systems, such as in Germany and Switzerland, provide another way, one which might be perceived as more in keeping with US values.”
What was especially laudable about Professor Reinhardt was that he really understood the global “big picture” of healthcare. His familiarity with a large number of national healthcare systems, including those of Germany, France, the Netherlands, Canada, and Australia, gave him the breadth of understanding to take on what he saw as the web of absurdities involving contradictory and ultimately defeating, incentives in the fee-for-service U.S. healthcare reimbursement system.
Dr. Reinhardt became ill and died just as the accountable care organization (ACO) phenomenon was really taking off, and as value-based care contracting was really beginning to take hold in the U.S. healthcare system; but I’m certain that he would be heartened, at least, to hear of recent developments around population health management, incorporating the social determinants of health into pop health, and the genuine collaboration beginning to take place now between health plans and providers. Indeed, his vision was all about collaboration and bringing down the walls between stakeholder groups in U.S. healthcare.
At this inflection point in the evolution of the U.S. healthcare system, we really could use Uwe Reinhardt’s voice more than ever. Fortunately, we have his legacy of thoughtful analysis and clearsighted ability to point out many of the key policy issues we continue to face healthcare system-wide, as the shift from volume to value begins in earnest. One can only hope that the value-driven system that emerges in the coming decades will be one that Dr. Reinhardt could applaud sincerely.
