GOVERNMENTSingle-payer advocates: Keeping up the fightPhysicians working for a universal health care system won't give up despite dismal political odds.By Geri Aston, amednews staff. Jan. 29, 2001. Each year 80,000 St. Louis residents filter through the nonprofit safety net health system that James Kimmey, MD, chairs. Its clients are the area's poor and uninsured. Despite St. Louis ConnectCare's successes, there is a significant portion of the community that doesn't have access to health services, Dr. Kimmey says. They are the people who fall through the cracks, who don't want to be viewed as charity cases or are overwhelmed by the paperwork involved in enrolling in a public program. "We see them when they have chest pains or acute respiratory episodes" -- conditions that could have been prevented with primary care, he says. Dr. Kimmey believes the health care access problem in St. Louis and elsewhere around the nation has a solution. The answer, he says, is a national, single-payer, universal health care system. It's been more than six years since the Clinton universal health plan failed. Washington policy-makers and lawmakers since then have turned to a step-by-step approach to expanding insurance access. Powerful lobbying groups, including the AMA, fiercely oppose the single-payer concept. Yet thousands of physicians, such as Dr. Kimmey, continue to press for it. Why? "What keeps us going is seeing the result of not having that kind of program every day," Dr. Kimmey says. He and physicians like him are frustrated that nearly 43 million Americans still lack health insurance and, as a result, often don't get appropriate, timely health care. On top of that, they are fed up with what they perceive as abuse at the hands of managed care companies. To them, the obvious solution is what many others consider extreme. "Our health care system is in trouble, and it will be in deeper trouble every day unless there is a fundamental change in the way we finance and deliver health care," says Alan Meyers, MD, associate professor of pediatrics at Boston University School of Medicine. "It will get worse for patients and physicians alike." One of the primary forces driving these physicians is their frustration with managed care. This, they say, is making their position more mainstream in the physician community. "I get angry when I have to spend time arguing with insurance companies about something I think the patient needs," Dr. Meyers says. Managed care has resulted in "little autonomy between physicians and patients," says Alice Rothchild, MD, a Boston obstetrician-gynecologist with Harvard Vanguard Medical Associates. Capitation puts primary care physicians in an adversarial role with patients, Dr. Rothchild adds. "This is so morally bankrupt." During the Clinton plan debates in 1993 and 1994, many physicians were "aghast" at the idea of government becoming so involved in the payment and management of health care, says E. Richard Brown, PhD, director of the University of California-Los Angeles Center for Health Policy and Research. They thought they would prefer a private market. "They've seen that monster, and many are expressing a preference for the government doing it rather than private insurers," he says. "So many physicians are discouraged at medical practice that it's a choice between abandoning their practice or looking to government or some other entity to rescue them from the clutches of insurers." Single-payer supporters point to Medicare, the Centers for Disease Control and Prevention, and the National Institutes of Health as successful examples of government involvement in health care. "The government would be better because it would have public accountability," Dr. Rothchild says. "I trust the CDC more than I trust insurance companies." Single-payer advocates point most often to Medicare as the closest thing to their approach. "This is an enormously popular program even with all its flaws," says Quentin Young, MD, a Chicago internist who sits on the board of directors of Physicians for a National Health Program, which has about 9,000 U.S. members. Medicare might not pay what providers want, but at least it's predictable, says Dr. Kimmey, who is also director of St. Louis University's Institute for Urban Health Policy. Managed care, meanwhile, tries to not pay at all, he says. Single-payer supporters say they understand that government-sponsored health care has problems, too. "It wouldn't be perfect," says Dr. Rothchild. "There would be battles. I'd much rather be arguing with the government." In Canada, funding for the health system was cut too far and the waits for elective surgery became too long, Dr. Young says. So with a national program comes a responsibility. "If or when we have universal health insurance, we will have to, as a people, elect representatives who understand that we want this much of the federal budget to go to health care," Dr. Young says. Single-payer advocates also are driven by their discontent with the fact that the United States spends more per capita on health care than any other developed nation, yet has nearly 43 million uninsured citizens. "How can we live in the wealthiest country in the world and have people with no health insurance?" Dr. Rothchild says. The nation spends more than $1 trillion on health care each year, almost $4,200 per person on average, so the resources are there, Dr. Young says. They just need to be reallocated. Betting on the statesSingle-payer advocates realize that the political outlook for their issue is grim in Congress. Instead, they are focusing on the states as possible incubators for their ideas. "If we can mount a strong enough effort in just one state, we'd have something to serve as a model," Dr. Meyers says. "If it works, then we're going to get somewhere." The issue came close to succeeding in Dr. Meyers' home state of Massachusetts. Last November voters narrowly rejected, 52% to 48%, a ballot initiative that would have required the state to develop in two years a plan to provide universal health care. The initiative's proponents blame the defeat on the expensive advertising campaign insurers and HMOs waged against them. They take comfort in the closeness of the vote. "With a disorganized campaign, no money and up against $5 million in negative ads, we almost tied," Dr. Meyers says. Single-payer advocates in Massachusetts are now regrouping, he adds. In general, states have not embraced the single-payer issue in recent years, according to data from the National Conference of State Legislatures. Universal health care was a topic in the 1999-2000 sessions of 12 states, but no major bills have become law. Just two bills calling for studies passed -- one in California and the other in Massachusetts. A state passing a universal health care bill is not inconceivable, says Richard Cauchi, NCSL senior policy specialist. "Sometimes states say, 'We're going to do something different. We know no one else does it,' " he says. Some single-payer advocates are hopeful that a bill by U.S. Rep. John Tierney (D, Mass.) will advance their cause. That measure would allow five states to receive grants to create universal health care systems. It would permit them to use Medicare, Medicaid, the State Children's Health Insurance Program and other federal funds on their state health programs. Tierney plans to reintroduce his legislation this year, says his spokeswoman, Carolyn Stewart. "He has been a long-time supporter of universal health care but sees that the national ship takes a long time to turn around," she says. "So trying to use states as laboratories might be a way to get ideas implemented faster." But chances for the Tierney bill are slim, according to some health analysts. "You can't take that [measure] seriously," says Stuart Altman, PhD, professor of national health policy at Brandeis University, Waltham, Mass. Incrementalism prevailsIn Washington, policy-makers, lawmakers and many health care groups think the best chance of achieving health care coverage for all Americans is with an incremental approach. "In the current political system, something step-by-step is the way to get there," says Bob Doherty, senior vice president for governmental affairs and public policy at the American College of Physicians--American Society of Internal Medicine. The political winds in Washington seem to be blowing in favor of expanding Medicaid and SCHIP, and creating federal income tax credits to help the working poor and middle class buy insurance. During his campaign President Bush proposed a tax credit plan and a loosening of SCHIP funding restrictions. The AMA has proposed refundable, income-based tax credits combined with purchasing cooperatives to increase access to insurance. ACP-ASIM advocates an expansion of Medicaid and SCHIP, along with carefully crafted refundable tax credits. "People who say single-payer or nothing will get nothing," says ACP-ASIM's Doherty. Single-payer advocates are thinking too narrowly, says AMA Trustee Donald J. Palmisano, MD. "They believe there are basically only two systems -- abusive managed care vs. single-payer," he says. "That's not the total universe of choices. "We need a pluralistic system of choices that allows patients to be in control with physicians as their trusted advisers," Dr. Palmisano adds. Single-payer supporters need to realize that there are other ways to accomplish their goal, says David Kendall, senior health policy fellow at the Progressive Policy Institute, a Washington, D.C., think tank. "Not only are they out of touch, they are likely to miss the best political opportunity to come to the uninsured in at least a decade," he says. Neither the AMA nor ACP-ASIM thinks doctors would approve of their treatment at the hands of a federal health bureaucracy. Doherty points to physicians' frustrations with Medicare, including the evaluation and management code controversy, as an example. Like managed care, the government also would "have to control costs somehow," he says, and might resort to many of the same tactics. Still, some say single-payer advocates serve a purpose. "If you look at any political change, you have someone pushing the edge of the envelope," Doherty says. "It's useful in galvanizing an examination of issues and challenging consciences." But single-payer advocates continue to reject the step-by-step reform approach. "Every one of the incremental inventions since Medicare has been either no help or a step back," Dr. Young says. With incremental reform, "it will be better a little bit for a little group of people for a little while," Dr. Rothchild says. Despite the overwhelming odds, the single-payer advocates plan to keep fighting. "We just keep plugging away," Dr. Rothchild says. "The alternative is too painful. If I give up, I'll have to leave medicine." ADDITIONAL INFORMATION:History of universal health care movement1915 American Assn. for Labor Legislation introduces a model bill limited to coverage for people earning less than $1,200 a year. Services of physicians, nurses and hospitals are included. Opposition from the AMA, labor unions and insurers sinks the effort.
Copyright 2001 American Medical Association. All rights reserved.
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