Proposals for US National Health Insurance Universal Health Insurance—Let the Debate Resume JAMA. 2003;290:818-820. The article by The Physicians' Working Group for Single-Payer National Health Insurance1 in this issue of THE JOURNAL should re-energize the much needed debate on universal health insurance. More than 40 million Americans lack health insurance2 and nearly 60 million are without health insurance for a portion of the year.3 Employers face rising health insurance premiums, and their employees face increasing cost-sharing. There are ongoing and increasing disagreements about health benefits coverage. Physicians, hospital administrators, home health agency financial officers, and others are increasingly frustrated with the confusion and inefficiencies of the current multiple payment mechanisms. In these fiscally troubled times, state legislators are having difficulty finding funds to support Medicaid and free-care pools. Clearly, there must be a "simpler and better way." Proposals for and debates surrounding universal health insurance certainly are not new. It has now been a decade since President Clinton put forth his Health Security Plan for universal insurance, some 30 years since President Nixon proposed his Comprehensive Health Insurance Program, and more than 5 decades since President Truman failed to get his proposed program enacted.4 Today, the issue of universal health insurance remains on the agenda because policymakers have been unable to reach agreement on what that "simpler and better way" is, and consequently have failed to act. Some might deny the dimensions of the problem, arguing that the uninsured receive free care at US hospitals and charity care from many of the nation's physicians. They know the proportion of US citizens who lack health insurance or are underinsured but cannot believe that translates into less care.5 Furthermore, some might argue that "the others" (ie, the uninsured) brought health problems on themselves by their lifestyles: if "they" would eat less, smoke less, drink less, and exercise more, they would need less medical care. Nevertheless, most Americans agree that the various reports documenting disparities in access and in health care, ie, those disparities related to insurance status, are compelling. Most Americans agree that they would not want to be uninsured or underinsured. Furthermore, most Americans are disturbed when they read that their physicians are pressed to work harder and faster even as their incomes decline, and most Americans believe that something has to be done about health care.6 Failure of the Clinton Administration's effort to reform the health care system served to virtually eliminate discussion of universal health insurance from the Conversely, when the Clinton effort failed, there was no agreement that government was required to find an answer and skepticism that it was wise enough to do so. There were no sustained educational efforts that continue into the present. Yet, from the perspective of the uninsured and the insured with higher cost-sharing, employers and governments with severe budgetary obligations, and physicians and other health care professionals, the problems have worsened and the valuable dollars spent trying to administer the dysfunctional system have increased. For these reasons, the article by the Physicians' Working Group is particularly important. Whether one agrees or disagrees with the approach that nearly 8000 physicians and medical students have endorsed, this group has provided a considerable service by fanning the almost extinguished spark called universal health insurance. Perhaps the most noteworthy aspect of this article is that by offering its approach, the Physicians' Working Group issues a challenge: those who reject its "solution" are challenged to present its own, better and stronger one as a replacement. Thus, it will not suffice simply to dismiss the Physicians' Working Group solution as unworkable. The American health care system and American society face a real problem and are compelled to search for an answer. The Physicians' Working Group proposal has the virtue of simplicity. For instance, Louise, from the well-known "Harry and Louise" advertisements against the Clinton proposal, might still say that there is a better way, but she could not complain that she cannot understand how the single-payer proposal would work. Indeed, she and tens of millions of Americans need only refer to Medicare to get the broad picture of the proposed "single-payer national health insurance," an expanded and strengthened "Medicare-for-all" system. The proposal also has the (not unrelated) advantage of administrative efficiency. Enrollment would no longer be related to employment (as with most private insurance) or income status (as with Medicaid). Similar to Medicare for those older than 65 years, the plan would reflect a "once enrolled, always enrolled" approach. Similarly, on the payment side of the ledger, a single rather than a set of multiple payers would reduce the administrative load on individual practitioners and hospitals. All patients would have the same broad coverage, and all payments would come from a single source. Not surprisingly, even as President Clinton rejected this approach, he indicated that this (Canadian-like) way of doing things would save millions of dollars.7 The proposal has numerous other features, one of which, although extraordinarily difficult to attain, would help return medicine to its earlier honored status—the elimination of for-profit institutions and the corporatization of medicine and return to the broad-based not-for-profit community hospital and prepaid group practice. Yet, the single-payer approach was rejected by President Clinton even as he spoke about its advantages. Similarly, others who believe that this "Medicare for all" system is the most efficient and most equitable answer have sought and moved to other alternatives. Why have they done so? Is it because there is a yet unmentioned weakness in the Physicians' Working Group proposal? Is it because some other alternative is inherently better? While some "dangers" are inherent in the proposal, these dangers most likely can be met by the exercise of democracy. If the money that fuels the system flows through government, it means that government may choose to spend too little and then try to compensate for that shortfall by reducing reimbursements, classifying drugs and procedures as "experimental" and not reimbursable, and engaging in other "shenanigans" designed to shift responsibility to others for the queues for appointments, decline in quality of nursing care, lack of capital investment, and so forth that may occur. That outcome is as true in medicine as it is in every facet of US society, including education, highways, national parks, bioterrorism defense, and the like. The ballot box is the answer. Given the dollars that now enter into election campaigns and the low voter turnout, that may not be an especially strong rod. Even so, it is a stronger rod to lean on and is likely to be more effective than an appeal to the kindness and generosity of the market that, in a quest for profits, may also "underspend." A second "problem" with the proposal is that it calls for a massive restructuring of the flow of dollars in the system. There is little doubt that this would affect labor-management negotiations and long-existing arrangements by which the money entering the system now flows. These matters can be managed, but there is no way around a single-payer approach requiring an increase in taxes. Although these taxes would substitute for existing premiums and out-of-pocket payments, they would be new and visible. It is clear, therefore, that such a proposal would require sustained efforts at education, strong leadership, and patience. Thus, the compelling reason this Medicare-like approach (which was taken very seriously in the late 1960s and early 1970s) has failed to receive political support in recent years does not lie in its analytical strengths or weaknesses, but elsewhere. The rejection comes because of a widely held view that the single-payer approach is too radical in that it simply is too much for the political system to handle, and therefore would never pass. This is not a position that can be dismissed lightly. In recent years the But Medicare took almost a decade to be enacted into law, and it is reasonable to argue that any comprehensive reform not only will, but should, take time—time for the nation to be educated, time for improvements in specifications to be offered, time for alternatives to be discussed, and time for defensible cost estimates and financing implications to be developed. Time is also needed to examine the principles, aims, and objectives of the single-payer proposal and consider whether those goals are attainable through other methods that trade off efficiency for political acceptability. Now is the time to reopen that discussion. The members of the Physicians' Working Group have done their job by raising the issue of national health insurance once again. Those who like their proposal should join with them. Those who do not should develop and propose something better, more effective, and with fewer untoward side effects. No one should sit back and bemoan the existing state of affairs. The "health care mess" is too real for anyone to ignore it.
Editorials represent the opinions of the authors and THE JOURNAL and not those of the American Medical Association. Author Affiliation: Department of Social Medicine, Harvard Medical School, Boston, Mass. To the Editor: The Physicians' Working Group1 pointed out many potential medical, economic, and societal benefits of NHI. For the estimated 45% of the It is currently impossible to accurately quantify the burden of chronic illness affecting future Medicare enrollees. Those who receive care do so from a large number of sources, and some do not receive care at all. One by-product of a single-payer system would be more accurate information with which to allocate medical resources for this rapidly growing segment of the population, which will require large amounts of medical services. This type of registry information is already available in many European countries and facilitates the study of the burden of illness affecting those populations. Such a registry would also be able to identify populations unaffected by chronic illness. From a public health and prevention standpoint, accurate knowledge of the burden of disease affecting different segments of the population would facilitate the development of population-level interventions designed to promote health in addition to treating disease. Elizabeth A. Bayliss, MD, MSPH 1. The Physicians' Working Group for Single-Payer National Health Insurance. Proposal of the Physicians' Working Group for Single-Payer National Health Insurance. JAMA. 2003;290:798-805. ABSTRACT/FULL TEXT 2. Chronic Conditions: Making the Case for Ongoing Care. Baltimore, Md: Johns Hopkins University Partnership for Solutions; 2002. JAMA. 2003;290:2799. To the Editor: Dr Woolhandler and colleagues, on behalf of the Physicians' Working Group for Single-Payer National Health Insurance,1 argued for the establishment of single-payer national health insurance (NHI). Details of their proposal—to require that physicians negotiate a binding fee schedule, prohibit hospital expansions and capital purchases, eliminate the health insurance industry, and require employers to transfer money earmarked for health benefits to the NHI program—represent the antithesis of freedom, choice, and private enterprise, the very hallmarks of American society. Single-payer, government-run health care cannot deliver the best medical care that Americans expect and now receive. Inherent problems include detrimental long waits for care, rationing, a slowness to adopt new technology and maintain facilities, and a gigantic bureaucracy that interferes with clinical decision making. The authors' continual references to the merits of the Canadian health care system contrast sharply with a recent report by Canadian physicians that concludes "we see continued turbulence . . . as a growing portion of Canadians lose patience with health care systems that they perceive as no longer delivering reasonable access to core services."2 Aaron3 has recently described analytic flaws in the analysis of Woolhandler and colleagues of differences between US and Canadian health care administrative costs, which form the basis of their methodology for single-payer national health insurance. In June 2003, the Chairman of the British Medical Association characterized his nation's single-payer health care system as "the stifling of innovation by excessive, intrusive audit . . . the shackling of doctors by prescribing guidelines, referral guidelines and protocols . . . the suffocation of professional responsibility by target-setting and production-line values that leave little room for the professional judgment of individual doctors or the needs of individual patients."4 His strong words come from long experience with a single-payer health system. In his Editorial, Dr Fein issued a challenge to those who reject the single-payer "solution"—present a better and stronger one as an option.5 The American Medical Association has a strong and viable solution—one that does not limit the universe of choices and that does not dictate a single-payer system as the only escape from managed care abuses. Our plan builds on current health care strengths and various options to ensure that Americans are covered by health insurance.6 Donald J. Palmisano, MD, JD 1. The Physicians' Working Group for Single-Payer National Health Insurance. Proposal of the Physicians' Working Group for Single-Payer National Health Insurance. JAMA. 2003;290:798-805. ABSTRACT/FULL TEXT 2. Detsky AS, Naylor CD. 3. Aaron HJ. The costs of health care administration in the 4. Bogle IG. Speech from the chairman of council, Dr Ian Bogle, CBE [outgoing speech as chairman of the British Medical Association Council. Speech presented at British Medical Association Representative Body Meeting, June 30, 2003, Torquay, 5. Fein R. Universal health insurance—let the debate resume. JAMA. 2003;290:818-820. FULL TEXT 6. Health insurance reform. American Medical Association Web site. Available at: http://www.ama-assn.org/go/insurance-reform. Accessibility verified November 6, 2003. JAMA. 2003;290:2797. To The Editor: In response to the Physicians' Working Group for Single-Payer National Health Insurance,1 I believe that the elimination of private health care would be objectionable in principle. In a free society, the government should not interfere with private transactions for lawful goods and services. If patients want to pay me twice the going rate for a visit or a procedure because they think I am worth it, they should be allowed to do so. Physicians who are better trained or who work harder than their peers should be rewarded with more money if they wish. It is disingenuous to pretend that medicine, alone among all human endeavors, will be free of economic incentives. I am also concerned that the elimination of private health care would be unpalatable. There is not yet enough support for the idea that every American deserves access to good health care that we can afford to alienate voters with a plan that can be characterized as overweening and unworkable. Although national health insurance may be an idea whose time has come, it does not need to be a monopoly to be effective. J. Timothy Ames, MD 1. The Physicians' Working Group for Single-Payer National Health Insurance. Proposal of the Physicians' Working Group for Single-Payer National Health Insurance. JAMA. 2003;290:798-805. ABSTRACT/FULL TEXT JAMA. 2003;290:2798. To the Editor: The proposal of the Physicians' Working Group for Single-Payer National Health Insurance1 largely ignores the shortcomings of a totally government-controlled health care system. Although the United States may have the most expensive system in the world, we also have the best. To eliminate the private sector smacks of socialism. As an example of the benefit of competition, a colleague and I founded National Medical Care, Inc, in 1968, which became the world's largest provider of dialysis care. As medical school faculty, we were frustrated by not being able to provide care for patients with chronic kidney failure even though the technology had already been developed. As described by McFeeley,2 we did so because the academic nonprofit community refused to provide care, opting for more "research" instead. Although dialysis clinics eventually would have been established anyway, it would have cost thousands of patient lives and taken several years. The for-profit system has played a pivotal role in providing care to all patients with kidney failure who could benefit, and at a far lower cost than would have been charged by hospitals.2 In the system proposed by the authors, such innovation would be very difficult, if not impossible. Competition is the lifeblood of any capitalistic system, and medicine need not be an exception if the rules are clear and followed. I also do not understand the authors' disdain for private health care if one is willing and able to pay for it. Their proposal would virtually eliminate a private alternative. Should everyone be driving the same car? Why do people work hard and become successful if they are not able to enjoy the fruits of their labor, especially when it comes to improving their health and that of their loved ones? A certain minimum of care should be provided, but if people want and can pay for more, why not? Constantine L. Hampers, MD 1. The Physicians' Working Group for Single-Payer National Health Insurance. Proposal of the Physicians' Working Group for Single-Payer National Health Insurance. JAMA. 2003;290:798-805. ABSTRACT/FULL TEXT 2. McFeeley T. The Price of Access. Nashua, NH: MDL Press; 2001. JAMA. 2003;290:2798. To the Editor: I am troubled that the Physicians' Working Group1 made no demand for individual responsibility. If health care is a public good, as the authors implied, then it is something that taxpayers pay for continuously, whether they use it or not. Such common public goods include police and fire protection and public sanitation. However, with each of these public goods, there is an explicit understanding of individual responsibilities. For example, although the fire department is there to put out fires in our homes, we have the responsibilty not to purposely start a fire and to have appropriate smoke detectors in our homes and businesses. If medical care becomes a public good, then should we not insist that individuals have responsibilities toward their own health? If we enforce mandates such as smoking cessation, exercise, and weight loss, what would be the punishment for those who do not comply? In fact, the Physicians' Working Group explicitly rejects this argument by saying that habits and behaviors will not be changed by their approach. Although mandating lifestyle changes might seem overly restrictive, the government has mandated other such restrictions in the past, such as use of motorcycle helments and seatbelts. In addition, the taxation required to implement such a single-payer policy would restrict the freedoms of the taxpayers who would lose the freedom to dispose of their money, since it was taken away from them to pay for national health care. How can the authors argue for restriction of some freedoms but not others? Vic Velanovich, MD 1. The Physicians' Working Group for Single-Payer National Health Insurance. Proposal of the Physicians' Working Group for Single-Payer National Health Insurance. JAMA. 2003;290:798-805. ABSTRACT/FULL TEXT JAMA. 2003;290:2798-2799. Correction to Woolhandler et al., N Engl J Med 349 (8) 768-775 August 21, 2003.
Costs of Health Care Administration in the United States and Canada To the Editor: There is little doubt that per capita health care administrative costs are lower in Canada than in the United States, as Woolhandler et al. report (Aug. 21 issue),1 even though the precise magnitude of the gap is open to debate, a point that Aaron makes in his accompanying editorial.2 However, the Canadian single-payer system results in chronic shortages of medical services because of underfunding. The underfunding problem is usually considered to be a separate issue from the single-payer system itself,2 but the very structure of the single-payer system may cause the problem. In the United States, persons who wish to spend more on health care than the norm have a simple way of doing so: they can purchase premium private medical insurance. Notwithstanding the Medicare prescription-drug plans currently being discussed, it is generally not an option in the United States to increase medical expenditures through the taxation system, given contemporary political and fiscal constraints. In Canada, however, increases in medical expenditures are possible largely only through the taxation system. And even if, as some surveys suggest, most Canadians are willing to spend more on health care,3 taxpayers cannot be sure that any given tax increase will actually go to health care expenditures. Therefore, Canadian taxpayers generally resist tax increases, and underfunding and chronic shortages result.
References Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. N Engl J Med 2003;349:768-775.[Abstract/Full Text] Aaron HJ. The costs of health care administration in the United States and Canada -- questionable answers to a questionable question. N Engl J Med 2003;349:801-803.[Full Text] Fife R. Most want surplus spent on Medicare, defence: liberal party poll finds overwhelming support for spending. National Post. December 27, 2002. Policymakers beyond America's borders, however, do read the Journal. They are not nearly so constrained by cultural blinders. During the 1990s, for example, Taiwan moved to universal health insurance coverage and opted for a single-payer system, after carefully studying health care systems abroad. Similarly, Canadian policymakers are forever being encouraged by critics to move Canada's health care system closer to the U.S. approach. These foreign policymakers and their policy analysts will find cross-national work on administrative costs highly relevant, quibbles over methodology notwithstanding.
With 21 business units diligently working to provide affordable health services to 50 million Americans, UnitedHealth Group will continue to invest in information technology and efficient business practices that reduce the cost of health care administration. We appreciate this opportunity to correct the record.
Since the implementation of nationwide health insurance, infant mortality and life expectancy have improved faster in We disagree with Sekhon that tax-based funding automatically means underfunding. In the Navarro and also Reinhardt and Cheng criticize Aaron's political judgment. His economic critique of our methods was also flawed, because it was based on incorrect assumptions about comparative wages. He started from a hypothetical example of a nation with wages 1/10 those in the Finally, Tuckson calls our attention to errors in Table 3 of our article. The correct enrollment figure for United Healthcare is 16,500,000, putting United Healthcare's number of employees per enrollee at the low end of
References Organization for Economic Cooperation and Development. OECD health data 2003. Toronto: Federal Publications, 2003. Szick S, Angus DE, Nichol G, Harrison MB, Page J, Moher D. Health care delivery in Woolhandler S, Himmelstein DU, Angell M, Young QD. Proposal of the Physicians' Working Group for Single-Payer National Health Insurance. JAMA 2003;290:798-805.[Abstract/Full Text] Reinhardt and Cheng observe that other nations can learn from the mistakes of the Reinhardt and Cheng also dismiss as a "quibble" my demonstration — based on one of several questionable procedures — that Woolhandler and colleagues overstate the difference between Canadian and Sekhon notes that a single-payer system need not ration care but can be readily used for that purpose. He sees the capacity to ration as a drawback, because rationing causes queues and other distortions. In contrast, I regard the capacity of single-payer plans to ration effectively as a potential virtue. The need to ration care for the well insured is rapidly becoming inescapable in the face of an avalanche of new and costly technology. No system of rationing will be free of distortions, and a single-payer system may do the job well or poorly, depending on how it is organized and run. But creating politically sustainable institutions to ration health care sensibly and compassionately is one of the leading challenges that our nation cannot avoid and has yet to meet.
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