America's robust economy may dominate the headlines these days, but the good news about economic prosperity masks the troubling story of our nation's health care. The U.S. Census Bureau estimates that 44.3 million people in the United States, or 16.3 percent of the population, were without health insurance in 1998 — an increase of about 1 million people since 1997.
The majority of uninsured Americans are employed full time or are the dependents of full-time workers. And, in fact, the number of working Americans with employer-sponsored health care coverage has declined from 69.2 percent in 1987 to 63.5 percent. Low-wage workers are disproportionately disenfranchised from employer-sponsored coverage and less able to afford coverage on their own.
Research shows that those without health insurance are more likely than the insured to delay or postpone needed medical care and to suffer adverse health outcomes.1
Family physicians see the consequences every day. That's one reason universal coverage remains a vital issue for family medicine and other primary care specialties.
Despite the failure of the Clinton administration's health care reform efforts, many physicians and physician organizations still consider universal coverage to be a visible strategy for caring for the uninsured.
To put universal coverage on the political agenda this election year, seven physician organizations, including the AMA and the AAFP, have joined forces to form the Physicians' Work Group on Universal Coverage (PWGUC).
The PWGUC is asking political candidates to create or support a plan to give health care to all Americans.
What's happening now?
In an effort to place universal coverage at the top of the nation's policy agenda, seven national physician organizations have joined forces to form the Physicians' Work Group on Universal Coverage (PWGUC). Initiated by the AMA, the PWGUC includes the American Academy of Pediatrics, American College of Emergency Physicians, American College of Surgeons, American College of Obstetricians and Gynecologists (ACOG), American College of Physicians-American Society of Internal Medicine (ACP-ASIM) and the AAFP. The group plans to use its organizational resources and a collective grass roots membership of more than 600,000 doctors to press political candidates on the subject of the uninsured.
“Professional medical societies cannot participate in partisan politics, but what we can do is describe the health effects that are the consequence of lack of insurance,” says Whitney W. Addington, MD, president of ACP-ASIM and chair of the PWGUC statement committee. “The most dramatic way of illustrating the problem of the uninsured would be to compare it to an epidemic. If we had a vaccine-preventable illness that was hurting 44 million people and increasing by 100,000 patients per month, physicians would call for a program to get that vaccine to those patients. The president would set up a special commission, and the CDC would obtain more funding.”
Citing unprecedented economic prosperity, Addington says that the time is right to create a system of universal coverage. To do that, the PWGUC is calling on all presidential and congressional candidates to commit themselves to either creating, or supporting, a plan to give health insurance to all Americans within their first year of taking office in the 2000 elections.
“Access to basic health care should be a given and we should work to bring the uninsured in under this umbrella of universal coverage,” says Lanny Copeland, MD, chair of the AAFP Task Force on Universal Coverage and PWGUC member. “We're a rich nation and we can afford this if we just put our heads together to tackle the problem.”
The PWGUC has no preconceived notions about how universal coverage should be achieved and it doesn't endorse any particular plan. Regardless of which plan is chosen, the group vows to advocate for three basic concepts:
All Americans must have health care coverage.
That coverage should include a quality benefits package.
Medical necessity determinations made under that benefits package should reflect generally accepted standards of medical practice supported by outcomes-based evidence.
Some members of the organizations that constitute the PWGUC are concerned about increasing the role of government in the health care system.
That concern is just one of several challenges faced by advocates of universal coverage. Others include a general resistance to health care reform in the wake of the failed health care reform plan advanced by the Clinton Administration, the belief that lack of coverage is not an obstacle to accessing care, concerns about cost and fears of rationing.
The resistance to reform
The failure of the Clinton plan has hampered subsequent reform efforts. But, according to John Queenan, MD, a member of ACOG's Committee for the Underserved and editor-in-chief of Contemporary OB/GYN, it's important to remember that the Clinton Administration failed largely because they focused on the proposition that nationalized health care was the best solution.
“I think universal coverage is a very viable strategy as long as people understand what we're talking about. It's not national health. It's not a single-payer, government-run plan,” he explains. “Rather, all forms of insurance coverage, private and public, would remain in place, including Medicare, Medicaid and CHIP (the Child Health Insurance Program). Universal health insurance would cover those without insurance. It's simply a matter of guaranteeing that there's a baseline level of insurance for everybody, so that nobody goes without preventive care.”
The myth of access
During the past decade, hundreds of studies have been conducted to document the plight of uninsured Americans. The ACP-ASIM white paper, “No Health Insurance: It's Enough to Make You Sick,” analyzes the findings of more than 100 of these studies. “The myth that lacking health insurance is merely an inconvenience and not a health risk is exploded in this paper,” says Addington.
The following are among the paper's conclusions:
Uninsured Americans tend to live sicker and die earlier than insured Americans do.
They are far less likely to have a regular source of care.
They are more likely to delay seeking care, even when ill or injured, and more likely to report unmet medical needs.
They are more likely to forgo annual exams, well-child care visits, prescription drugs, eyeglasses and dental care.
They are more vulnerable to adverse health outcomes.
ACP-ASIM white paper: “No Health Insurance: It's Enough to Make You Sick”
Uninsured Americans tend to live sicker and die earlier than insured Americans. That's the major finding of the white paper “No Health Insurance: It's Enough to Make You Sick,” released in November 1999 by the American College of Physicians-American Society of Internal Medicine (ACP-ASIM). The ACP-ASIM research staff culled through more than 1,000 studies to identify the 100 described in the paper.
The research suggests that insurance is a primary factor in health care access. Uninsured Americans are far less likely than the insured to have a regular source of care or to use preventive services, and they are more likely to delay seeking care and to report that they have not received needed care. The white paper also includes the following findings:
Have a generally higher mortality rate and a specifically higher in-hospital mortality rate;
Are up to four times more likely to require both avoidable hospitalizations and emergency hospital care;
Are less likely to receive follow-up care after hospital discharge;
Are almost five times less likely to obtain prescription drugs.
Are up to 10 times less likely to have a regular source of care;
Are five times more likely to use the emergency room as a regular place of care;
Are twice as likely to have gone without a physician visit during the previous year;
Are up to six times more likely to have gone without needed medical care.
Among the paper's major conclusions
Millions of Americans are unable to receive the care they need, endangering the health and lives of patients, adding costs to the health care system and reducing productivity.
Missed or delayed care may result in unnecessary sickness or death and greater severity of illness.
The uninsured use more expensive treatment for preventive, acute and chronic care because they often obtain medical care in the emergency department rather than in a physician's office. According to the National Center for Health Statistics, nonurgent cases account for more than half of emergency department visits.
The inability of the uninsured to take advantage of preventive care also increases the nation's health care costs. For example, uninsured pregnant women seek prenatal care later in pregnancy, if at all, increasing the probability that newborn care will occur in a neonatal intensive care unit.
A copy of the complete report is available online at http://www.acponline.org/ppvl/policies/e000304.html.
The “cost” for physicians
“The absence of universal coverage almost guarantees the daily experience for a family physician of having patients whose management is going to be determined by their lack of coverage,” says Larry A. Green, MD, director of the AAFP Center for Policy Studies in Family Practice and Primary Care. Universal coverage is one of the themes guiding the early work of the Center. “These days it's not uncommon for patients to ask how much a medicine or a test costs, and then ask the doctor to use something else instead,” says Green.
That's a familiar experience for Carlos Gonzales, MD, a family physician and member of the AAFP Task Force on Universal Coverage. Gonzales runs a satellite clinic in Patagonia, Ariz., that is affiliated with the Mariposa Community Health Center in Nogales, Ariz. Although most of his patients are employed, 30 percent to 40 percent are uninsured. Many work in construction or ranching, and their employers don't provide insurance.
“Despite the fact that the clinic is busy and we get federal subsidies and I participate in all of the insurance programs that I can, it's still marginal financially,” says Gonzalez. “The main clinic in Nogales is always looking at my small clinic to see if it's worthwhile keeping me here because there just aren't enough paying patients. Yet right now I'm the only doctor for 1,600 square miles. So if they close this clinic, there will be no one here to provide care.”
While many fear that universal coverage will bring additional paperwork burdens, Gonzales doesn't believe it will be a problem. “I work under 15 MCOs. Believe me, the paperwork can't get any more complicated. Actually, if we had universal coverage for the basic stuff, it would make my billing life easier because I would know the treatment is covered. As it is now, I treat patients knowing the bill will not be paid,” he says.
And it's not just his own charges Gonzales must worry about. “When a patient needs an expensive test like an MRI or a CT scan, it's difficult for someone without insurance to come up with from $300 to $1,500 for the test. And when I have to send them to a specialist, I have to beg the specialist to make an exception or to design a billing program so the patient can pay over time. And then I have to do the same for the hospital,” he says.
Why the controversy?
It's likely that under universal coverage, all Americans would have access to basic health care services through some type of public-private partnership. The debate surrounding universal coverage is about who will be asked to pay — the government, employers or individuals — and how the services will be financed. Some of the more frequently mentioned approaches for funding universal coverage are listed below.
Individually funded using tax incentives
Tax breaks for the self-employed
Medical savings accounts
The American worker
Many think the best place to begin to reform health care is to build on what's already available — especially for the working population.
American workers value having employers as their health plan sponsors and prefer it to directly purchasing private health insurance, says Cathy Schoen, vice president for research and evaluation at The Commonwealth Fund, a New York City-based foundation that researches health and social issues.
According to the findings from “The Commonwealth Fund 1999 National Survey of Workers' Health Insurance,” most workers with employer-sponsored coverage think their employers do a good job of selecting quality plans and would like to see employers continue as a source of coverage. They'd also favor reforms to expand employer-sponsored coverage or to provide similar benefits to workers who are currently uninsured. Eighty-five percent of respondents would favor proposals to help workers pay their share of employer-plan premiums; 79 percent would support a new public insurance program for low-wage workers; and two-thirds would support expansion of current government programs to provide coverage for low-wage, uninsured workers.
“It isn't surprising that people want to stay with the system they know,” says Schoen. “And for a solid core of those working for a living, the employer-based system has worked quite well. So as we look for solutions for covering people who have been left out and for making benefits more widely available, we don't want to do anything to destabilize or erode coverage that is providing good benefits for workers.”
The concerns about cost
In 1997, the last year for which figures are complete, health care spending in this country reached $1.17 trillion. That's $4,005 for every person in the country. Switzerland ranks a distant second to the United States, spending $2,400 per capita.
“The United States is the only developed country without universal health care. What we have in this country is an individual-oriented, high technology kind of medicine,” says Daniel Callahan, PhD, director of international programs and co-founder of The Hastings Center, an independent, interdisciplinary research center addressing the issues of health, medicine and the environment.
“Our typical approach is to spend a lot of money on technology to save lives, much less money on trying to prevent the need for it in the first place,” he says. “We need to shift to more of a population focus. We should be interested in the kind of medical progress that really improves the health of populations.
ACOG's Queenan agrees. “By focusing on the health of the uninsured, universal coverage would actually save money while improving the health of the general population,” he says. “It costs more to provide crisis care than it would to reap the benefits of early detection and reduced morbidity and mortality by covering screening. By providing universal coverage, we'll ensure universal access to preventive care. We'll also eliminate much of the administrative trivia involved in getting authorization and precertification to establish eligibility before taking care of the patient.”
The fear of rationing
“Americans seem to fear the big R word, ‘ration,’” says the AAFP's Green. “Yet we already explicitly ration. Instead of rationing goods and services, the United States rations people. The 45 million people who go without health insurance — that's how we ration. Oregon rations by relating the health care services they provide for the people of Oregon to the budget available to provide those services.” Green is referring to the Oregon Health Plan, which was crafted when Oregon Gov. John Kitzhaber, MD, an emergency physician, was president of the Oregon Senate (see below).
“One lesson to be learned from the Oregon Health Plan is that you can in fact prioritize medical services on the basis of criteria such as clinical effectiveness and social value,” Kitzhaber says. “Another lesson is that you can actually have a discussion about limits and about prioritization without negative political consequence. I was very closely identified with the Oregon Health Plan and with dealing with limits. That was in 1989-90, and I've been elected governor twice now. I believe the public is way ahead of public policymakers in terms of their willingness to have a conversation about limits if people they respect conduct the conversation.”
The Oregon Health Plan
Between 1989 and 1995, Oregon enacted legislation to provide access to affordable health insurance to all state residents. The plan, known as the Oregon Health Plan, extends Medicaid eligibility to all state residents with incomes below the federal poverty level, establishes a high-risk insurance pool for people refused coverage because of pre-existing conditions, provides small businesses with a range of insurance options and enables employees to maintain insurance when changing jobs.
Coverage for those who can't pay is funded through general tax revenues.
“The lessons of the Oregon Health Plan lie not in the specifics of the plan, but rather in the process by which it was enacted,” says Gov. John Kitzhaber, MD, who was president of the Oregon Senate when the legislation was enacted.
The process included having the state's Health Services Commission (a group of medical professionals and consumers) rank a list of “medical condition/treatment pairs” (gleaned from CPT and ICD-9 codes) from most important to least important in terms of health outcomes. The commission considered clinical effectiveness as determined by panels of physicians and social values as determined by a poll of state residents and a series of town hall meetings.
Services that ranked highest on the list were for acute fatal conditions for which treatment could prevent death and return the patient to health. Those that ranked at the bottom of the list were services for minor conditions, “futile care” and services that would have little or no effect on health.
The legislature was statutorily prohibited from altering the commission's rankings. Instead it was required to start at the top of the list and determine how much could be funded from available revenues and what additional revenues would be needed to fund an acceptable basic health care coverage package.
“The question of what is covered is directly linked to the reality of fiscal limits,” says Kitzhaber. “Because of the explicit nature of the process, the legislature is clearly accountable not just for what it funds in the health care budget, but also for what it chooses not to fund. Our prioritization process provides a context for making choices.”
The physician as advocate
According to Kitzhaber, today's health care marketplace is designed to make a profit, not foster social responsibility.
“I think the single most important thing we can do is to develop a payment mechanism so that all people can afford some level of care,” he says. “That's then going to force us to have this larger discussion of what we can afford to pay for with public dollars.”
“The medical profession can help ensure that this is a much more productive debate than it has been in the past,” he says. “Physicians can bring to the table a strong moral position about the importance of universal coverage and also an honest recognition of limits. And we're the only profession that can provide good information about what is clinically effective and what isn't. I think if we focus on our strong suit from that strong moral position and become advocates for access, we can lead the way in talking about appropriateness and effectiveness of care. And I think we'll achieve an enormously influential position in the health care debate.”