Health Insurance Care

Universal Health Insurance Let the Debate Resume

Rashi Fein, PhD

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 US public policy agenda.

This attempt to expand insurance was quite different from the debate about Medicare. That

effort was sustained over almost a 10-year period (1957-1965) during which the American

public and its legislators came to understand the "problem" and the various ways that

persons across the political spectrum, from Senator Taft to Senator Anderson, preferred to

solve it. The bill that was finally enacted represented a major improvement over the

measure that was first submitted. That improvement was, in part, the result of educational

efforts that engaged all protagonists and the public at large and, in part, because of

agreement that elderly persons faced real problems in obtaining health insurance and that

government had to find a solution either through the public sector, the private sector, or,

as it turned out, some combination of the two.

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. America's physicians have never looked to

government as their savior. However, while they were guarding their flanks against "big

government" and its power, they were blind-sided by employers who discovered they could

bargain with insurers over benefits and premiums, by insurers who responding to

employers exercised control over issues of productivity, requiring more "output" at lower

reimbursement, and by managed care organizations who organized delivery systems that

tried to preempt the physician's independence and exercise of clinical judgment. Although

American medicine may fear government's exercise of arbitrary power, government is

accountable. The real danger lies in the faceless, inexorable, profit-motivated market, an

institution from which there is no appeal.

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 US political system

has provided little evidence of its ability to handle major comprehensive legislation. The

electorate and the Congress are closely divided, and the days of true bipartisanship that

operated under a slogan of "come let us reason together" seem to have been replaced (at

least, temporarily) by a certain mean spiritedness that does not search for compromise, but

advantage. There is little agreement that government has to find (or be part of) an answer

to the health insurance problem. It hardly seems to be a time for more than incrementalism

(at best) and, most assuredly, that is not what a single-payer system is.

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.

AUTHOR INFORMATION

Corresponding Author and Reprints: Rashi Fein, PhD, Department of Social Medicine,

Harvard Medical School, 641 Huntington Ave, Boston, MA 02115 (e-mail:

**********@***.*******.*** ).

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.

REFERENCES

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. FREE FULL TEXT

2. The Kaiser Commission on Medicaid and the Uninsured. Chartbook [Health Insurance

Coverage in America: 2001 Data Update]; 2003. Available at:

http://www.kff.org/content/2003/4070. Accessibility verified July 22, 2003.

3. Congressional Budget Office. How Many People Lack Health Insurance and For How Long?

May 2003. Available at: http://www.cbo.gov/showdoc.cfm?index=4210&sequence=0.

Accessibility verified July 22, 2003.

4. Litman TJ, Robins LS. Health Politics and Policy. 3rd ed. Albany, NY: Delmar Publishers;

1997.

5. Ayanian JZ. Unmet health needs of uninsured adults in the United States. JAMA.

2000;284:2061-2069. FREE FULL TEXT

6. Henry J. Kaiser Family Foundation Kaiser Health Poll Report, January/February 2003

Edition. Public opinion on the uninsured. Available at:

http://www.kff.org/healthpollreport/templates/summary.php?feature=feature3. Accessibility

verified July 11, 2003.

7. Clinton gives governors outline for health reform. The Washington Post. August 17,

1993:z13.

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