By Steffie Woolhandler, M.D., and David Himmelstein, M.D.
PNHP note: The two articles below describe the founding of Physicians for a National Health Program. The articles span a quarter-century – one was written shortly after the organization’s founding, the other was written in October of this year. We reproduce them here, the most recent one first, as part of the observance of PNHP’s 25th anniversary and as a contribution to understanding its continuing mission.
We initiated PNHP in the summer of 1986 at a meeting of about 200 clinicians caring for the poor organized by Lucy Candib and Gene Bishop in New Hampshire.
Several factors led us to propose this new organization to colleagues:
1) Fifteen years after the nationwide implementation of Canada’s Medicare program, research by us and others had recently documented the striking advantages of the single-payer approach in terms of access to care and cost efficiency.
2) After five years of the Reagan administration assault on safety-net program, we were convinced that efforts focused on defending existing safety-net programs (e.g. Medicare and Medicaid) and institutions (public hospitals and community clinics) could not protect our patients. The public programs were (and are) woefully inadequate.
· Medicare, despite its positive aspects, covered less than half of the total medical expenses of the elderly; privatization had started with the 1985 Medicare HMO program; and providers siphoned billions, taking advantage of the payment system that had been adopted from private insurers.
· Medicaid patients were often unwelcome at doctor’s offices and private hospitals; and private HMOs were beginning to make incursions into this program too.
· Clinics and public hospitals, where we ourselves practiced were chronically starved of resources and hence provided separate and unequal care for minorities, the poor and the poorly insured.
Defense of these woefully inadequate approaches meant defending substandard (if valiant) care.
3) Advocacy for national health insurance (NHI) or a national health service (NHS), which had been a powerful force in the 1960s and 1970s, had largely died out. The scattered supporters of these different approaches, who had previously been sharply divided, seemed ready to collaborate. Moreover, experience in Canada and the U.K. challenged the traditional view that an NHS necessarily offered a more thoroughgoing reform than NHI. Canada’s single-payer NHI banned competing private insurance, mandating that all Canadians get care from a single, unified medical care system. In contrast, many wealthy Britons opted for private coverage, offering them an escape from the NHS. We chose the name “Physicians for a National Health Program” to avoid the old fights about NHI vs. NHS.
4) We sensed a growing dissatisfaction among colleagues with the then incipient corporate domination of medicine, which was being stimulated by the emergence of HMOs and managed care. Many doctors seemed ready for an alternative.
5) A ballot initiative in Massachusetts instructing congresspeople to support single-payer reform was the immediate trigger for our initiative. A group of Massachusetts Gray Panthers – Dave Danielson, Art Mazer and Gerry Bergman, among others – had succeeded in getting the question on the ballot. They were concerned that the Massachusetts Medical Society might openly oppose the measure and encouraged a public display of physician support for single payer.
At the New Hampshire conference, colleagues reacted enthusiastically to our proposal. Discussion centered on whether the new group should be a physicians’ organization or seek to organize a broader constituency.
Influenced by the Massachusetts Gray Panthers’ request for support from a group specifically identified as physicians, and the belief that many physicians supportive of single payer would hesitate to join a broader group, we chose the PNHP path. But we agreed that PNHP should be part of a broader “Network of Health Professionals for a National Health Program” (NHP2), and eventually “People for a National Health Program.”
Several colleagues who remain active in PNHP participated in those discussions, including Oli Fein, Howard Waitzkin, Gordy Schiff, Mardge Cohen, Henry Kahn, Jeff Scavron and Len Rodberg. (We are surely forgetting many others). Len offered to create a database program to maintain the membership list (an esoteric feat in 1986). Milton Terris volunteered to have stationary printed (including NHP2 stationery).
Following the conference, we set about enlisting colleagues willing to be listed as “Founding Members” on a membership solicitation letter that we had drafted, which outlined the essential elements of a single-payer reform. Many responded positively.
Aided by Steffie’s sister (who spent some months with us in Cambridge) we mailed membership invitations to several thousand colleagues, using lists obtained from other physician organizations. By late 1987, about 200 dues-paying members had signed up.
From the outset, there was general agreement that the group should draw up a single-payer physicians’ manifesto, with the hope that it could be published in a major journal, allowing us to increase our legitimacy and recruitment. In early 1988 we met with Arnold Relman, the editor of the New England Journal of Medicine, to explore whether he was open to publishing such an article. He made no commitment, but expressed interest.
We set about drafting an article, with extensive feedback from 28 colleagues who formed the writing group. Relman eventually accepted and published the article, which appeared on January 12, 1989.
The New England Journal’s publication of PNHP’s proposal was greeted as a “man bites dog” story by the press. Colleagues in several cities organized press conferences to reach out to the lay media. We and many other PNHP colleagues were interviewed by major media outlets, and PNHPers made appearances on national television programs including “The Today Show,” “Good Morning America” and the “Mac
Neil/Lehrer NewHour.” PNHP had arrived as an organization, and memberships flowed in by the dozens.
The surge in membership allowed us to hire a staffer to take over maintenance of the membership database and other essential tasks, and necessitated moving the organization’s office out of our home. Bob Lawrence (our department chair at the time) agreed to allow us to utilize our hospital offices to house PNHP.
From the outset, PNHP was envisaged as a membership-driven organization, focused on providing opportunities for progressive physicians to express their views in an effective manner. We were convinced that a large number of physicians each spending a modest amount of time on PNHP work could accomplish far more than a few paid staffers. Moreover, leadership that was intimately aware of the daily realities encountered in medical practice was essential to assure that PNHP remained relevant to physicians. Hence, the staff role was not to lead, but to facilitate communication among the members, and to assume many of the burdensome tasks of maintaining the organization’s infrastructure.
Another feature of PNHP that was established early on was a monthly conference call for active members to share information and ideas for effective action. Many of the early members of PNHP went on to start local chapters, and the monthly phone call provided them with regular support and inspiration.
Our first experience with an executive director was an unfortunate one. Several months after starting work, she became convinced that adhering strictly to the single-payer message compromised our possibilities for funding. (We later learned that a foundation had let her know that watering down PNHP’s advocacy agenda would result in a substantial donation.) She asked PNHP’s newly formed board – led by Jeff Scavron, the first PNHP president – to make this change in focus, and eject us from the organization. Instead, the board unanimously endorsed our approach and dismissed the staffer.
Subsequently Judy Kaplan took over as the staffer in Cambridge, followed by Donna Pound. Both performed yeoman service, helping us to initiate the PNHP Newsletter.
Communicating with Colleagues
Shortly before PNHP was initiated, Malcolm Peterson (chief-of-staff at the Seattle VA) had invited us to present the case for single-payer reform at a session he chaired at the American College of Physicians annual meeting. Responding to Malcolm’s invitation, we assembled a raft of slides for the presentation, adopting a traditional, data-intensive grand rounds style. The positive response to the presentation bolstered our view that many physicians would more readily embrace the single-payer message if it were communicated in such a traditional format.
Ike Taylor, who had moved to Boston after retiring as dean of the University of North Carolina School of Medicine, helped to shape these presentations. He had sought us out after reading the New England Journal article. Ike dived into PNHP activism on many fronts, and agreed to assume the PNHP presidency.
As invitations for presentations grew, many PNHP colleagues became skilled speakers on single payer, often using the PNHP slide set, which was updated annually and widely distributed.
Further publications in the JAMA outlining PNHP’s views on quality improvement (led by Gordy Schiff); financing (in collaboration with Kevin Grumbach and Tom Bodenheimer) and long-term care (led by Charlene Harrington) fleshed out key aspects of PNHP’s program, and gained visibility for the organization.
Moving to Chicago
In 1991 a decision was made to move PNHP’s headquarters to Chicago. This decision was motivated by several factors.
- We were planning a sabbatical year in Washington and hence would not be present at the Cambridge office.
- We and others felt it important to broaden leadership of the organization.
- Ron Sable, a dynamic and much loved physician who had founded the AIDS program at Cook County Hospital was stepping back from clinical work because of illness, and was available to assume the role of coordinator, supported by the very strong Chicago PNHP cohort that included Quentin Young, Gordy Schiff, and Claudia Fegan
- Chicago made sense as the home base of a national physician organization.
Ron and Quentin skillfully built PNHP in Chicago. Taking advantage of an opportunity to share office space with another group Quentin chaired, the Health and Medicine Policy Research Group (focused on Illinois health policy issues), the new office of PNHP opened on January 1, 1992. Ida Hellander, who was working at Sid Wolfe’s Public Citizen Health Research Group where David spent his sabbatical, was recruited to join them in leading the Chicago office.
After Ron’s death in 1993, Quentin Young stepped in to the role of national coordinator.
Quentin and Ida vastly increased PNHP’s recruiting efforts and public visibility, turned our periodic meetings from small, informal affairs into well-organized, dynamic gatherings, and greatly facilitated membership communications. With help from Mike McCally, they secured grants from three foundations and tripled the budget.
Claudia – at that time a partner in Quentin’s practice – and Gordy both assumed an increasingly critical role in the organization, serving as PNHP Presidents, traveling speakers, and unofficially helping to oversee the Chicago office.
With Bill Clinton’s election and the 1993-1994 health reform debate, single-payer advocates swung into action. Vicente Navarro, included in the White House task force at Jesse Jackson’s insistence, remained firm in advocating single payer from the inside, and Several PNHP representatives were invited to present their case to Hillary Clinton. Once the Clinton plan was unveiled, a lively debate within PNHP resulted in a clear stance to continue single-payer advocacy, and point out the flaws in the Clinton plan – prefiguring PNHP’s position on President Obama’s reform plan.
The subsequent years brought new energy and leadership from colleagues across the nation. We are certainly omitting the names of many who played foundational roles in PNHP’s earlier years, both nationally and in building chapters around the country.
Physicians for a National Health Program:
Report from the United States
By Steffie Woolhandler and David U. Himmelstein
International Journal of Health Services, 1987
A new organization called Physicians for a National Health Program (PNHP) is mobilizing physician support for a universal, comprehensive public system of health care for the United States. Recent changes in power relations within medicine (the so-called proletarianization of physicians) are prodding many physicians to abandon their traditional reactionary role in health policy. PNHP is working with elderly, labor, community, and health care activist groups to put a national health program (NHP) back on the U.S. health policy agenda. In this article, five key features of an NHP needed to simultaneously assure access, control costs, and minimize bureaucracy are noted.
Physicians have long been a bulwark of conservatism in U.S. health policy. Organized medicine has opposed virtually every initiative to extend access
to services and democratize health care decision-making. As corporate control increasingly threatens the preeminent position of physicians (1), a significant portion of the medical profession appears ready to break with this tradition of reaction. Physicians for a National Health Program (PNHP) is a new organization attempting to crystallize and direct the growing discontent of physicians into support for a national health program (NHP).
An NHP is the only stable solution to the widely perceived crisis in U.S. health care. There is overwhelming evidence that an NHP could provide universal access to high quality care and control costs. In contrast, current health policies have failed to contain costs and have exacerbated problems in both access to and quality of care. Health care costs (corrected for overall inflation) have risen more rapidly over the past six years than during the last half of the 1970s. This escalation occurred despite, or perhaps because of, the growing preoccupation of policy makers with cost control through competitive strategies, health maintenance organizations (HMOs), prospective reimbursement, and the like. Meanwhile the number of people without health insurance increased 43 percent between 1978 and 1985, and both physicians and hospital social workers report feeling pressured to discharge patients from hospitals prematurely.
While cost control initiatives have failed to control costs, they are rapidly changing power relations within health care. These recent initiatives have shared a common thread – they offer financial incentives for hospitals, HMOs, and insurers to control physicians and patients. Much of the recent cost increase is attributable to the growing administrative structure required to operate health care as a profit-making capitalist industry and enforce inequality in access to medical services. Administration consumes at least 22 percent of U.S. health spending, in contrast to 6 percent in the United Kingdom and 8 percent in Canada (2). U.S. physicians increasingly confront hospital, insurance company, and other corporate bureaucracies that dictate the parameters of medical care. Marx’s classic description of the evolution of an industry appears germane. The power of physicians as independent petit bourgeois medical producers is rapidly giving way before the onslaught of corporate control (3).
The U.S. public has long supported an NHP (4), a support that was reaffirmed by the 67 percent majority of the Massachusetts electorate who voted for the National Health Program Referendum in November of 1986. Surprisingly, 56 percent of physicians also favor some form of NHP, though three-quarters of doctors are convinced that most of their colleagues oppose such reform (5). Unfortunately, politicians, wary of threatening insurance companies and other elements of the medical-industrial complex, persist in dismissing an NHP as utopian and unpopular. In this context, we are convinced that physicians can help place an NHP on the political agenda. There will undoubtedly be considerable struggle over the precise form of an NHP in the United States, and aspects of many proposals will threaten the selfinterest of physicians. However, we believe that the following features are both crucial to progress in health care and attractive to many physicians.
1. Coverage must be universal and comprehensive, including coverage of preventive, curative, mental health, occupational, and rehabilitative care. This could assure access to care, avoid a two-class system, and minimize administrative expense. Allowing balance billing, competing private insurance, or out-of-pocket payments negates these advantages.
2. Hospitals should be paid on an annual lump sum basis for operating expenses. This would minimize incentives for both undercare (since hospitals could not retain a surplus) and overcare (since excess services would not generate additional income). Lump sum budgeting also streamlines administration since billing is eliminated.
3. Payment for capital costs must be separated from hospital operating costs and physician fees. If hospitals can buy new buildings and equipment with surplus funds from their yearly budgets, they have a strong incentive to skimp on care. Real health planning becomes impossible since rich hospitals can continue to expand, while areas without sufficient resources will remain underserved. Similarly, paying physicians for capital such as office-based computed tomography (CT) scanners encourages unnecessary purchase and use of such expensive equipment.
4. Private insurance companies should be excluded from any NHP. Public administration is cheaper, and allows much more democratic control of key policy decisions. Private insurance firms have incentives to increase costs and bureaucracy since these result in higher income. Reimbursement decisions are important public policy and must be recognized as such.
5. Public accountability should be encouraged, but should not be confused with bureaucratic dominance a la diagnosis related groups (DRGs). Detailed administrative oversight of clinical practice (e.g., how many EKGs should be allowed for a patient with a myocardial infarction) should be discouraged. Such oversight costs as much as it saves, and is unnecessary if financial incentives for or against the use of technology and services are minimal.
The Canadian NHP meets many of these criteria, and offers a concrete, though flawed, point of reference in mobilizing support for an NHP in the United States. We recognize that Canadian health care remains largely a sickness care system, dominated by a bourgeois medical model, antagonistic to “alternative” providers, basically insufficient in its approach to social and environmental problems, and riven by class inequalities among
health workers. Nonetheless, Canada has achieved a surprising degree of equality in access to health services, without excessive costs. The Canadian working class is no longer threatened with the termination of coverage in case of unemployment, strikes, or disability. We have found the real-life experience of the Canadian NHP vital in countering the powerful disinformation campaign against public medicine, and in answering the hundreds of what-if questions that arise in discussion of an NHP. The early, enthusiastic response to PNHP confirms that many physicians are prepared to embrace the concept of an NHP.
The Canadian experience demonstrates that monopsony government payment for health care can assure considerable public control of health resources and personnel despite private ownership and practice. In contrast, the British National Health Service owns most health facilities and employs most personnel, but coexists with a private sector. This allows for two-class care, as well as the underfunding of the public sector since the well-to-do can seek care elsewhere. The Canadian experience also suggests a possible strategy for overcoming political obstacles to an NHP. The Canadian NHP originated in Saskatchewan, where a socialist provincial government introduced a province-wide health insurance plan. The spark from Saskatchewan spread rapidly across the prairie resulting in a universal, comprehensive health care program throughout Canada within five years. Statewide demonstration projects in states with relatively progressive regimes might provide a similar springboard for winning a nationwide program in the United States.
PNHP is actively pursuing outreach to the physician community through presentations at conferences, grand rounds, and public forums. The decision to organize a physicians’ group followed several months of discussion. PNHP’s founders felt that a broader group could not attract many sympathetic physicians who are not already activists. PNHP is seen as a part of a Network of Health Professionals for a National Health Program, which can amplify the voices of existing organizations like the Coalition for a National Health Service, and the National Association for Public Health Policy. We are already working jointly with elderly and community organizations to formulate proposals for statewide demonstration programs in Massachusetts and a few other states.
To join PNHP or obtain information on our activities, write: Physicians for a National Health Program, Center for National Health Program Studies, Department of Medicine, The Cambridge Hospital, 1493 Cambridge Street, Cambridge, MA 02139. [PNHP note: PNHP’s current address is Physicians for a National Health Program, 29 E. Madison St., Suite 1412, Chicago IL 60602.]
1. McKinlay, J. B., and Arches, J. Towards the proletarianization of physicians. Int. J. Health Serv. 15(2): 161-196, 1985.
2. Himmelstein, D.U., and Woolhandler, S. Socialized medicine: A solution to the cost crisis in health care in the United States. Int. J. Health Serv. 16(3): 339-354, 1986.
3. Himmelstein, D.U., and Woolhandler, S. Medicine as industry: The health sector in the U.S. Monthly Rev. 35(11): 13-25, 1984.
4. Navarro, V. Where is the popular mandate? N. Engl. f. Med. 307: 1516-1518, 1982.
5. Colombotos, J., and Kirchner, C. Physicians and Social Change. Oxford University Press, New York, 1986.
International Journal of Health Services, Volume 17, Number 4, 1987.
© 1987, Baywood Publishing Co., Inc. http://baywood.com