The time is right to fix the problem of the uninsured

AMA Leader Commentary. By Richard F. Corlin, MD Jan. 21, 2002.

AMA LEADER COMMENTARY

A few words about current events in medical practice

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A message to all physicians from AMA President Richard F. Corlin, MD.

In September, I had a lung biopsy, and the next day boarded a plane to Chicago to attend an AMA board meeting. Over Kansas, I experienced a sharp stabbing pain in my chest. I made it to Chicago, where I rushed to the emergency department of Resurrection Hospital with a pneumothorax. After a few days of observation, I took the train home to Los Angeles, where I checked into UCLA Hospital. There, a resection of my left lower lobe showed a benign carcinoid tumor, no mitotic figures and no tumor cells in any of the lymph nodes.

Every doctor, nurse and health professional I dealt with was kind, caring and -- above all -- competent. And my health insurance paid for all of that first-rate care. My positive experience with everyday American medicine has given me an insight into correcting the issue of the uninsured. That is, most of our health care delivery system is working very well and should not be discarded under the guise of correcting the problems of the uninsured or any other aspects of health care that need our attention.

Most prior efforts to insure the uninsured have failed because the desire has been to replace everything in our system with something new and untried. This scares off the large majority for whom the system works well. I think I always understood this at an intellectual level. Now, through my own experience, I know it at a personal and emotional level as well.

The AMA proposal to help the uninsured recognizes that our system needs neither a political quick fix nor an ideologically based overhaul, but change that depends on the private sector to do its part. Let's quickly summarize our AMA proposal:

We endorse the concept that employers provide a defined contribution for the purchase of health expense coverage -- rather than a defined benefit.
Our proposal supports a system in which all Americans with health coverage are given tax credits -- in amounts inversely correlated with their income -- rather than excluding employer-provided health benefits from their taxable income.
We also support the creation of opportunities for alternative health insurance markets -- "voluntary choice cooperatives" -- that would offer more choices for individuals than are presently available.
Universally available medical savings accounts play an important role in this consumer-oriented system.

The advantages of the system we propose are many:

Our proposal emphasizes the patient's role in affordable health insurance coverage, offering choice, coverage and cost effectiveness -- all in a single package.
It shifts the decision-making about health coverage from employers to employees and gives them a way to pay for it themselves.
The AMA plan connects the individual health care consumer to the cost of care.

As of the end of 2000, 39 million Americans did not have health insurance coverage. Eight out of 10 of those people are in working families that cannot afford health insurance and are not covered by state or federal health programs.

In 2001, those statistics worsened because of a recession economy as well as the terrorist attacks of Sept. 11. Last month, Families USA, a consumer health group, released a report showing that more than 725,000 workers laid off in 2001 lost their health insurance coverage. Almost half of those workers (345,000) lost their coverage in September and October, in the wake of the terrorist attacks.

We know that the uninsured live sicker lives and die younger. And that's why we need to do something about our fellow citizens who cannot find or afford health insurance. The AMA proposal calls for larger tax credits for those with lower incomes -- even refundable tax credits so those very low-income people who don't have to pay taxes would still be able to purchase health insurance. This would help retain the security of health care coverage for those without jobs. Another advantage of this kind of system is that people wouldn't have to change insurance plans or doctors as they often have to now. And the AMA plan would also help to develop in each and every individual a consciousness of the real costs involved in their health care choices.

If we combined the full enrollment of individuals eligible for coverage under Medicaid and the State Children's Health Insurance Program, our proposal would cover 94% of the uninsured. All at the relatively modest cost of $30 to $60 billion of federal spending (in addition to the estimated $80 billion that is now available in the form of eliminating the current tax subsidy of employment-sponsored health benefits).

There is a successful precedent to the AMA system -- and it's one that Congress enjoys. Under the health care insurance system that covers members of Congress and other federal employees, the employer pays a fixed amount, and allows the employee to select whichever health insurance plan he or she wants from a list of approved offerings. Employees are not forced to take the plan their employer has selected. Why don't all other employees in this country have the same options? We think they should.

To date, our nation has been unable to deal successfully with the unconscionable problem of the uninsured. But now the time is right. We should all be grateful for the efforts of the Robert Wood Johnson Foundation to build political will for action on the uninsured. RWJ is underwriting the second phase of a multimillion-dollar campaign to build support for expanding coverage for the uninsured. The administration and influential members of Congress believe in the use of tax credits to expand coverage. Our AMA has communicated our desire to work with the nation's leaders on this issue.

Winston Churchill probably said it best when he commented that you can always count on the Americans to do the right thing -- after they have tried everything else. When it comes to dealing with the medically uninsured in this country, we have tried everything else, so now it's time to do the right thing. Individually and collectively, we can help. Let me know what you think about our plan.

Dr. Corlin, a gastroenterologist in private practice in Santa Monica, Calif., served as AMA president during 2001-02.