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Quest for coverage: Insuring the uninsured

The destination is agreed upon -- health care for all Americans -- but the road is jammed by differences of opinion on how to get there.

By Joel B. Finkelstein, amednews staff. April 7, 2003.

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Universal health care, single payer, coverage for all. No matter what you call it, America seems to be moving toward wholesale reforms that promise to change the face of how physicians deliver care.

The medical community, politicians and academics agree that current health care trends are unsustainable.

The United States spends more on health care per capita than any other developed nation, yet more than 41.2 million people were uninsured in 2001. A growing number of Americans lack reliable access to physicians and medical services. Increases in health insurance premiums were in the double digits again last year, making it more difficult for employers and workers to continue paying for coverage. States are staggering under massive Medicaid budgets. And Medicare costs are expected to explode with the aging of the population.

"The basic concern is that the patchwork [of health coverage] is just not working," said Jay H. Glasser, PhD, president of the American Public Health Assn. The situation is only going to get worse, he added.

In the past couple of years, recognition of these problems and the ultimate collapse of the current system they are expected to precipitate has generated an increase in reform proposals from all sides of the debate.

While the Bush administration and industry groups believe they can save the system by placing a heavier reliance on private health plans, proponents of more radical changes that would do away with market competition altogether also have gained a voice on Capitol Hill.

Many states are having their own go at the problem. Legislatures in California, Maine, Maryland, New Mexico and Oregon are discussing proposals. States may prove a useful testing ground for many ideas, with successful strategies for universal coverage spreading from state to state before becoming national policy, according to the Universal Health Care Action Network.

In recent years, physician-supported groups, such as UHCAN and Physicians for a National Health Program, have gained some momentum in their push toward broader coverage. And organizations such as the American Medical Association, the American Nurses Assn. and the American Hospital Assn. have come together to form the Cover the Uninsured alliance. The AMA favors establishing health insurance tax credits and creating more opportunities for individuals and families to buy affordable coverage.

Whatever the result, experts and advocates are calling for physicians to play an important role in improving outcomes and efficiency of health care delivery as part of any new universal system.

Single payer, single headache?

Conceptually speaking, a single-payer system is simplicity itself. Legislation at the state and federal level call for a Medicaid- or Medicare-type government agency that would provide health coverage to everyone, thereby cutting down on administrative costs and eliminating the need for advertising and high-salaried executives.

Further savings and benefits would be realized by eliminating market forces, proponents say. For example, unlike health plans, a single-payer system would not need to hire nurses and accountants to limit the cost of care.

"The hallmark of our [current] system is how funds are diverted to overhead," said Marcia Angell, MD, senior lecturer at Harvard Medical School's Dept. of Social Medicine. Dodging sick people is expensive business, and physicians get shortchanged in the process, she added.

These nurses and people working in ancillary services for the managed care industry could be working with patients, said Minesh Shah, a fellow at the American Medical Student Assn. Given the current shortages of these professionals, many of those who would be put out of work by the demise of managed care would not have far to look for new jobs, he said.

Proponents of single-payer health care also promise that such an approach would simplify administrative hassles for doctors' offices because they would have to deal with only one payer, rather than the paperwork requirements of multiple public programs and private health plans.

Such a system would guarantee physicians a steady revenue stream, said Rep. Jim McDermott, MD, (D, Wash.). It would not require any delivery system changes. Physicians' offices would still operate as private business, not government employees, he said.

Dr. McDermott also argued that single-payer health care does not necessarily lead to rationing, as some opponents charge. Managed care, on the other hand, limits services all the time, he noted.

A national health plan also could include incentives for physicians to improve outcomes, rather than to limit services, said Alan Sager, PhD, co-director of Boston University's Health Reform Program.

"Financial incentives to underserve patients are clearly repugnant" to physicians, Dr. Sager said. Ultimately, physicians should be where the buck stops. It comes down to whom do you trust to spend health dollars wisely, he said. "I'd like to trust doctors."

But opponents of a single-payer system point to the red-tape headaches of public programs in arguing that an injection of government bureaucracy is the last thing the faltering health care infrastructure needs.

Pointing to Medicare's "arcane and problematic" administration, Stuart M. Butler, PhD, vice president of domestic and economic policy studies at the Heritage Foundation, recently testified to a Senate special committee that "this Byzantine process is marked by intense pleading by medical specialty societies and a degree of congressional micromanagement that makes efficient management of the program impossible."

The political fate of single-payer proposals is not so rosy, either. Despite growing support among Democrats and moderates in Congress for legislation to establish a national health plan, even staunch proponents of universal health care think such a strategy has little chance.

"The problem is not economics, and not medicine, it's politics," Shah said.

Other advocates seem to agree that political realities may be an overwhelming obstacle. "While a single-payer system is a very good model of what is optimal ... you often have to come up with suboptimal solutions," said Kenneth Frisof, MD, national director of UHCAN. "But the solutions, to paraphrase Martin Luther King, have to bend toward justice."

But the obstacles don't daunt some. "Many people say that the single-payer system is a good idea but politically unrealistic, but that's a self-fulfilling prophecy," Dr. Angell said. "In my opinion, the medical profession and the public would be enthusiastic about a single-payer system if the facts were known."

The alternative

Opponents of a single-payer system are also beginning to realize the importance of public opinion.

At a recent meeting, Alain Enthoven, PhD, a health economist at Stanford University, warned managed care executives that if they don't address the rise in health spending and the uninsured, they would be handing a victory to advocates of a system that does not include them.

"The strongest argument against single payer is that a well-designed market model could perform much better," Dr. Enthoven said. But "the apparent merits of single payer will grow if we can't offer an alternative."

That other option is a system that more effectively meshes public and private coverage, according to White House officials.

The managed care industry was born out of the need to curtail rising health costs. It soon came under fire for restricting care and now is criticized for failing to control health spending.

According to Sen. John Breaux (D, La.), the goal of health system reform should be to "let the government do what it can do best and the private system do what it can do, and add a layer of public responsibility."

Proposals that have been forwarded by Breaux and others would preserve the makeup of the private insurance market while shifting responsibility for purchasing insurance to patients through tax subsidies that would target individuals, rather than groups of employees. Putting money and information in consumers' hands would create incentives for the health insurance industry to develop new, affordable products, they say.

This also would foster competition among physicians. Patients with more choices are better informed and more conscientious consumers, economists say.

In such a market atmosphere, physicians likely would gravitate toward well-managed independent practice associations and other forms of organized physician networks. Physicians gradually would find themselves working more within a team than on their own, and, as a side benefit, also would have more control over their practice hours, said Dr. Enthoven.

Consumer choice and control are important concepts in these proposals and would make patients more cost-conscious, giving physicians more influence over how health dollars are spent, he said.

But noneconomists demur. "It's a myth that we have a system of choice today," said David Himmelstein, MD, an internist at Cambridge (Mass.) Hospital and a co-founder of Physicians for a National Health Program. "While the president would have us shift millions of seniors to private coverage in the name of efficiency and choice, not only would there not be choice, but the efficiency is clearly not there."

Dr. Himmelstein said that while Medicare costs have risen precipitously, they have still grown more slowly than managed care premiums.

Politically, however, strategies to enhance the current system, which include reform of Medicare, Medicaid and the tax system to provide more fairly distributed subsidies, seem to be more viable. The Bush administration already has pushed for such changes, and congressional leadership stands behind them. They also have received some support from the managed care industry.

Let's talk about it

Recognizing major differences of opinion on how to reach universal coverage, a group of organizations would like to see the various proposals placed on the table for public discussion and debate. "There are multiple right ways and multiple wrong ways" of achieving the goal of providing coverage for everyone, UHCAN's Frisof said.

Instead of focusing on saving money, a reformed health care system should, at the very least, include incentives to improve patient safeguards and the delivery of care, as well as ensure equity and fair payment for services, said the public health association's Dr. Glasser.

"Most of the problems [with the system] have been articulated at this point," he said. Now it is time to get doctors, patients, academics and politicians together, set a deadline and start working toward solutions.

As long as the stakeholders keep their eyes on the goal of providing everyone with reliable access to basic health care, everything else is negotiable, said the medical student association's Shah.

"We are the wealthiest nation," he said. "With a lot of innovation, we can come up with our own system."

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