Donald W. Light, Ph.D., responds on the increased funding for the British National Health Service:
The NHS reforms under Tony Blair go much farther than to make up for years of underfunding, which previous Prime Ministers denied was the case. Mr. Blair and Mr. Milburn have open acknowledged central flaws in the NHS that resulted from compromises that Bevan had to make to the medical profession in 1948, and they are rectifying them all.
Severe shortages in nearly every subspecialty are coming to an end. The lack of quality standards is being addressed more systematically than here. The coordination of training of all clinical staff is starting up (like the vision out of PEW in the 1990s here but unlikely to be realized). The hospital-centric system is being systematically transformed into the obverse, with community-based primary care as the center of the system and with GPs and community nurse teams holding the budgets for nearly all health care. These will be population-based and risk-adjusted, roughly what David Kindig envisions in Population-Based Purchasing (Wisconsin 1996). The waiting lists are being transformed. They will be taken away from consultants and coordinated through referral centers. Patients will be given appointments as much as possible. The conflicts of interest in the consultants' contract are being replaced with productivity-based terms. This is a reform I have been working to bring about for several years, and the Blair Government has accepted most of the recommended changes.
There are serious problems in implementing all this, but the design and vision are worth serious attention by anyone interested in a population-based, community-centered model of health care like that envisioned in the Dawson Report of 1920. I have written several short pieces on aspects of all this as I have worked on the reforms every quarter since 1990.
Don Light
Prof. Donald W. Light
Fax: 1-609-924-1830
Tel: 1-609-924-9220
AMA President Richard Corlin's insensitive remark on the uninsured provoked more responses than any prior "Quote of the Day" message. Barbara Rylko-Bauer eloquently expresses the innate emotional response that most of us felt on reading his words. My comments follow hers.
Barbara M. Rylko-Bauer:
Dear Don:
According to your "quote of the day," Dr. Richard Corlin, president of the AMA, during a trip to Cedar Rapids last week, was supposed to have said the following with regards to the uninsured:
"We need a pragmatic, not an ideological solution. Reduce the number from 39 million to its irreducible minimum, probably about 15 million, and consider that a victory and not a terrible tragedy."
If Dr. Corlin truly did say these very words, then I think that all responsible physicians should call for his resignation...for he has served medicine and the physicians he represents, as AMA president, very poorly, to say the least.
By responsible physicians I mean those :
* who consider that their role is not just to treat a disease that walks in the door, but also to be concerned about larger health care issues facing communities and populations,
* who are compassionate,
* who are concerned with what is happening in health care delivery in this country... NOT just in relation to how it affects medicine's autonomy, not just in relation to how it is affecting doctor-patient relations, not just in relation to how it affects their pocket book...(ALL valid things to be concerned about.)... but also in terms of how it is affecting the patients they are privileged to treat,
* and who are concerned about all the other people who ARE NOT patients because they have no real access to care.....in other words, those pesky uninsured folks that Dr. Corlin so readily dismisses.
Dr. Corlin should also do a little reading about the state of affairs of health care in the United States. He might discover that it's not just those 40 million that are the "problem." There are also another 40 million or so who are unstably insured (with gaps during the year) or underinsured. What, oh what, are we going to do with them?
Of course, the bigger question is why, in the wealthiest country in the world, which in the year 2000 spent $1.3 trillion on health care --- that averages to $4,637 per person....(but of course, not distributed evenly) --- we even have to be discussing problems like:
* the large and growing number of people who are uninsured,
* the fact that despite all our advanced biotechnology, we are plagued with serious safety and quality problems in health care delivery,
* the large racial and ethnic disparities in health care delivery,
* and the fact that our headlong race to embrace a market-oriented health care system (of which managed care is just one part) has undermined the "health care safety net" which so many of the poor and vulnerable populations rely on?
These are all topics that the prestigious Institute of Medicine of the National Academy of Science has been exploring. Within the last few years there have been in-depth reports published on all these topics. We are not talking here about some tangential problems, but rather things that are AT THE CORE of health care delivery in the United States. I would be happy to order copies of these for Dr. Corlin... to help him get "up to speed" about the state of affairs for health care in the United States.
I am not a physician. I have, however, studied U.S. health care for many years, as a social scientist. I am frankly astounded that in this day and age, a physician could so glibly erase 15 million people, could stand up and publicly say that if we got the numbers down to 15 million, we could pat ourselves on the back and say, "job well done." And then to have the insensitivity (and amorality) to consider that having ONLY 15 million uninsured would be a victory, not a tragedy...it boggles the mind. I am also, as a scholar-of-sorts, curious as to how he came to this magical number of 15 million as the "irreducible" denominator. Not from studying health care delivery in other industrialized countries; from where, then?
Dr. Corlin should do even more reading and find out WHO these uninsured folks are....
* he would find out that most of them are employed, hard-working citizens who are in lower paying jobs or with small firms that can't afford health insurance;
* he would find out that 5.9 million of them are mothers;
* he would find out that about 1/4 of them are children;
* he would find out that many of them are members of minority groups.
I would be willing to bet that herein lies one of Dr. Corlin's problems. I am looking at a picture of Dr. Corlin as I write...and I can tell you that he:
* is not one of the hard-working poor, not even one of the hard-working middle income Americans who simply can't afford health insurance,
* is not one of those 5.9 million mothers with small children,
* is not, obviously, a child,
* and is most likely not a member of a minority group.
Dr. Corlin can't relate to these folks. What I can't tell from the picture, but can tell from his remarks of last week, is that Dr. Corlin is not a true physician. And he has shamed his profession and his professional position with the irresponsible remarks he made in Cedar Rapids last week. He owes all the uninsured people of this country an apology....and he also owes one to the physicians he is supposed to be representing, as president of one of the major medical associations.
With Dr. Corlin at its head, organized medicine is beginning to look a bit like a ship adrift, these days. Doctors dropping Medicare, opting out of Medicaid, setting up boutique practices, complaining loudly about the abuses of managed care (and there certainly is plenty to complain about, that I agree with) but going along with the for-profit program for the most part, and largely remaining silent about the ways in which big business is shaping health care delivery for its own interests. Its time for more courageous, visionary leadership....and some better ideas for how to solve the problems of health care delivery in this country.
Sincerely,
Barbara Rylko-Bauer
Comment: Dr. Corlin's apparent insensitivity mandated responses such as Barbara's. But Dr. Corlin is not the evil person implied by his isolated comment. He is a very fine person, representing the best of the Hippocratic traditions in medicine. So how could he have made such an awful statement?
Health policies that the members of the AMA leadership support include tax credits, MSAs, shifting costs (risk) to individual patients, multiple health plan products (multi-tiered benefits), and eliminating the employment link for health insurance. Dr. Corlin is aware that these policies can never provide true universal coverage. His comment was based on his belief that the AMA policies are in the nation's interest, and that we have to accept the consequences of these "great" policies. We accept that employment rates will never be 100%, and, likewise, we should accept that health insurance coverage will never be 100%. From his perspective, his comment was a very benign remark on the realities of health care reform.
But what a remark! The AMA leaders are so sold on the righteousness of their approach that they cannot see the cruelty and inhumanity that would be inflicted on those for whom they should be leading the charge: the patients that are most in need of health care! The outrage expressed in response to Dr. Corlin's comment should bring the AMA Board of Trustees out from their board room to find out what the ruckus is about.
Actually, Dr. Corlin and other members of the AMA leadership, in their tours of the communities, are hearing more and more from many members of the medical profession that we should be taking a very serious look at single payer reform. It is time for the AMA and state and county medical associations to set aside their conservative political ideology and rhetoric, and place on the table all options for reform. It is essential that all policy implications be clearly understood and discussed objectively. The single payer model would provide equitable, comprehensive coverage for absolutely everyone while providing free choice of providers of care and controlling costs. The policies currently supported by the AMA would accomplish none of those goals. But they are goals truly worthy of pursuit.
Don McCanne