Commentary by Zackary Berger MD PhD, PGY-2
In the political arena, reforming health care is continually a major domestic issue. It’s no surprise that the lead 2008 democratic contenders cite the same statistic on each of their websites, “Nearly 45 million Americans, including 9 million children, are without health insurance.” Moreover, on each of their sites, the candidates ambitiously describe plans that would provide universal and affordable healthcare for all Americans. Their tactics largely entail expanding Medicaid, holding employers more accountable to providing coverage, and lowering costs by modernizing healthcare.
The presidential candidates are not alone in their plight to reform healthcare. The true movers and shakers of reforming healthcare are professional organizations and advocacy groups, both of whom have inspired a number of solutions which can be organized into two broad categories, incremental or single-payer. The current democratic political candidates generally support incremental healthcare reform. A true single payer system would require an extreme change of our current system.
In a single payer system, universal coverage is provided by a single public agency that organizes health financing, yet care is still delivered by private providers. More recently, nationalized health care has garnered more attention by Michael Moore’s new documentary Sicko, which contrasts the US system with the universal health care systems of Canada, France, the UK, and Cuba. The advocacy group “Physicians for a National Health Program” (http://www.phnp.org) provides information about the benefits and practical implications of a single-payer health care system in the US. The list of members of its advisory board includes their organizational affiliations, but (as its name indicates) the group is composed of physicians, not medical organizations or professional societies.
Incrementalism is a less radical approach to healthcare reform and is supported by The National Coalition for Covering the Uninsured (NCCU), a broad-based coalition of a number of organizations, including the AMA, the American Hospital Association, the American Public Health Association, the American Academy of Family Physicians, pharmaceutical companies, insurance companies and other organizations. Given the divergent range of interests and philosophies represented by this list, it’s understandable that the NCCU’s plan involves a number of less wide-reaching improvements in the current system, including transparent pricing; personal Medical Savings Accounts; and the expansion of public programs to cover the very poor.
Many national medical organizations support these solutions in greater or lesser measure. Their “home” positions may in many cases differ from their compromised positions hammered out in coalitions with others. The American College of Physicians, on its web site, advertises its support for the Health CARE Act, a proposal which would increase federal matching funds to those states expanding Medicaid coverage to all those beneath the federal poverty level, and which would also provide increased federal funding to those states which increase coverage for uninsured children. For its part, the American Medical Association “will strongly advocate for incremental measures to expand coverage,” and in keeping with this advocacy is a member of the NCCU. In the long term, says its web site, it will continue to push for the adoption of a market-based plan to expand coverage, “relying upon incentives and voluntary approaches.” Similarly, the American College of Surgeons endorses universal access to care “within our current pluralistic health care system,” i.e. to be incremental in the pursuit of change, with some features being implemented on a state by state basis. The ACS further emphasizes that “reducing health care costs [through improving information technology] is much more desirable than containing costs by rationing care.” Compared to other professional organizations, the American Academy of Family Physicians is full-throated in its advocacy of a plan to ensure health care coverage for all. On its web site, it lists those services which should be covered for all who reside in the United States (a relevant distinction in these days of proposed immigration reform). Assured services with no co-payment include prenatal/maternity care; well baby/child care; evidence-based childhood and adult immunizations; and evidence-based periodic evaluation and screening services. Other assured services, including outpatient physician services and outpatient prescription medications, would require 20% co-payment. The AAFP is also the rare organization which specifies a funding mechanism: a national, broad-based tax. Under the AAFP plan, coverage would be rationed by a “resource-based relative value system.”
The differences in positions, taken on their own and as participants in coalitions, of the American professional medical organizations and advocacy groups remind practicing physicians, and especially physicians in training, that the current health-care system can justify various solutions. Advocacy can also be modified in coalition for the sake of practical lobbying. Personally, I think a single-payer system is the only solution that would fix the gaping inequities in our system, but I also realize that there are many ways of getting there. PNHP might better fit idealists, while NCCU, realists, but they have a goal in common: reducing the numbers of the uninsured. Perhaps the coalitions can themselves coalition to force the problem of the uninsured even higher on the agenda of the 2008 elections and, hopefully, hold the winning candidate accountable to their ambitious promises.