JAMA – The Journal of the American Medical Association
August 13, 2003 Editorial
Universal Health Insurance – Let the Debate Resume By Rashi Fein, PhD
The article by The Physicians’ Working Group for Single-Payer NationalHealth insurance in this issue of THE JOURNAL should re-energize the much needed debate on universal health insurance.
Whether one agrees or disagrees with the approach that nearly 8000 physicians and medical students have endorsed, this group has provided a considerable service by fanning the almost extinguished spark called universal health insurance. Perhaps the most noteworthy aspect of this article is that by offering its approach, the Physicians’ Working Group issues a challenge: those who reject its “solution” are challenged to present its own, better and stronger one as a replacement. Thus, it will not suffice simply to dismiss the Physicians’ Working Group solution as unworkable. The American health care system and American society face a real problem and are compelled to search for an answer.
Now is the time to reopen that discussion. The members of the Physicians’ Working Group have done their job by raising the issue of national health
insurance once again. Those who like their proposal should join with them.
Those who do not should develop and propose something better, more effective, and with fewer untoward side effects. No one should sit back and bemoan the existing state of affairs. The “health care mess” is too real for anyone to ignore it.
http://jama.ama-assn.org/cgi/content/full/290/6/818
The abstract of the proposal:
http://jama.ama-assn.org/cgi/content/abstract/290/6/798
The full proposal:
http://jama.ama-assn.org/cgi/content/full/290/6/798
To view the list of endorsers:

Physicians for a National Health Program

For physicians who wish to add their endorsement:
http://www.physiciansproposal.org/

The Washington Post
August 5, 2003
A Fight for Free Access To Medical Research
Online Plan Challenges Publishers’ Dominance
By Rick Weiss
Why is it, a growing number of people are asking, that anyone can download
medical nonsense from the Web for free, but citizens must pay to see the
results of carefully conducted biomedical research that was financed by their taxes?
The Public Library of Science aims to change that. The organization, founded
by a Nobel Prize-winning biologist and two colleagues (Harold Varmus,Patrick O. Brown and Michael Eisen), is plotting the overthrow of the system by which scientific results are made known to the world — a $9 billion publishing juggernaut with subscription charges that range into thousands of dollars per year.
In its place the organization is constructing a system that would put scientific findings on the Web — for free.Scientists and budget-squeezed librarians have long railed against publishers’ stranglehold on scientific literature, to little avail. But with surprising political acumen, the Public Library of Science — or PLoS
— has begun to make “open access” scientific publication an issue for everyday
citizens, emphasizing that taxpayers fund the lion’s share of biomedical research and deserve access to the results.
“It is wrong when a breast cancer patient cannot access federally funded research data paid for by her hard-earned taxes,” Rep. Martin O. Sabo(D-Minn.) said recently as he introduced legislation that would give PLoS a boost by loosening copyright restrictions on publicly funded research. “It is wrong when the family whose child has a rare disease must pay again for research data their tax dollars already paid for.”
http://www.washingtonpost.com/wp-dyn/articles/A19104-2003Aug4.html
Comment: Should the results of publicly-funded medical research be placed in the public domain, or should the results remain the intellectual property of others, marketed by copyright-protected scientific journals? Should we continue to support the superfluous middleman publishers who control access for the purpose of profit, or should we establish our own “public library” with universal access and lower administrative costs?Just as we are reassessing the high costs, administrative excesses and restricted health care access through our system of private health plans, we should also be reassessing the unnecessary costs and restricted access to the results of medical research that we have funded.

The Guardian
July 16, 2003
The oldest and still the best
By Malcolm Dean

In the battle between 10 and 11 Downing Street over the NHS (National Health Service), Gordon Brown has always pushed two arguments for continuing with the current structure: first, that it is even more important today than its launch in 1948 because of its capacity to do so much more; second, because of the spiraling cost of modern medicine, which requires a comprehensive national insurance, such as the NHS, to provide the necessary protection.

If the chancellor had been at an international conference of leading policy makers last week, he would have learned a third reason: the advantages a national health system enjoys over federal or fragmented health systems.

…there are the new initiatives Labour has introduced nationwide: inspectors, systematic assessment of new drugs and equipment, new standards and a modernisation agency. They were described by Sheila Leatherman, an American researcher, who has been looking at their impact as “the most ambitious, comprehensive and intentionally-funded national initiative to improve health care quality in the world”.

But the initiative that generated the most jealousy was the new IT (Information Technology) system that will link all parts of the NHS for the first time: an extra £2.5bn over three years on top of the £2.4bn already planned. Currently there is no coordination among thousands of different systems. This will be a major step towards a crucial goal: better integration of primary care and hospital services.

The US has been trying to do this for years, but has been thwarted by its multiple systems, special interest hospital and insurance lobbies, and deeply fragmented services.

http://politics.guardian.co.uk/comment/story/0,9115,998723,00.html

Comment: It is remarkable what can be accomplished in an integrated system, even with very modest funding. The United States has proven that no amount of funding can correct the dysfunction of a fragmented system designed to meet the needs of special interests such as insurance companies.

Just imagine what 15.2% of the GDP, our current level of health care spending, could do in a universal, integrated, publicly administered system. But then, let’s not merely sit around and contemplate such an altruistic system. Let’s enact it.

(Note: There will be no Quote of the Day messages for the next two weeks while we are in Canada contemplating their altruistic system.)

The Washington Post
July 17, 2003
Editorial
Medicare Robbery

… Medicare’s universality. Many Democrats and some Republicans consider this to be Medicare’s central attraction. It is a program, they say, that gives the same benefits to everybody, rich or poor, and therefore receives universal political support. To preserve this universality, many are fighting against a provision in the House bill, for example, that calls for people with incomes above $60,000 to pay a larger share of their drug bills. They object on the grounds that nobody should be treated differently.

This kind of thinking helps to illustrate what has gone so deeply wrong with the bill, a piece of legislation that seems to be oblivious to its long-term consequences. In practice, the refusal to countenance any means-testing will set in motion a vast transfer of wealth, from the pockets of America’s poorer children — who will eventually be working adults — to America’s wealthier elderly. The desire to maintain political support for Medicare is understandable, but the zealous opposition to any reform that would provide fewer benefits for the rich is profoundly misplaced. It guarantees the swindling of a generation that cannot vote in order to benefit a wealthy constituency that can.

http://www.washingtonpost.com/wp-dyn/articles/A3480-2003Jul16.html

Comment: The editorial staff of The Washington Post supports destroying Medicare as a program of social insurance. Introducing means testing would result in a mass exodus of affluent beneficiaries into the private sector. The traditional Medicare program then would undergo de facto conversion into a welfare-type Medicaid program, but with even fewer benefits, not to mention the inevitability of deficient funding.

The editors support means testing as a method of preventing “a vast transfer of wealth from the pockets of America’s poorer children.” But an equitable system of progressive funding is much more readily assured through the tax system rather than through a fragmented system of differential qualification for benefits. Measures as simple as exempting from the Medicare tax wages that are necessary to meet basic needs would go a long way toward establishing equity.

We cannot afford to abandon the concept of social insurance. In fact, we need to expand it to include all of us.

Health Affairs
Web Exclusive
July 16, 2003
Which Way For Federalism And Health Policy?
What’s right, and what’s wrong, with the federal-state division of
responsibility for health care.
By John Holahan, Alan Weil, and Joshua M. Wiener

Abstract:

The current balance of responsibility between states and the federal government for low-income people’s health coverage has achieved a great deal. It covers many of the neediest people, supports the safety net, responds to emerging needs, and supports some experimentation. However, it leaves more than forty million people uninsured, allows excessive variation across states, places unsustainable pressure on state budgets, creates tension between the two levels of government, and yields too few benefits from experimentation. This mixed record argues for a significant simplification of and increase in eligibility for public programs, with the federal government either providing extra funds to states to meet these needs or assuming full responsibility for insuring the poor.

From the Conclusion:

The current balance of federal and state responsibilities for health insurance coverage has achieved a great deal. But it has failed to insure forty million Americans, it expands coverage in small steps only, and under it no state, much less the nation as a whole, has developed and implemented a comprehensive approach to covering the uninsured. The states are now largely playing defense against an eroding employer base of coverage and a fiscal future in which Medicaid expenditures are likely to grow faster than revenues. There is no reason to believe that the current federal structure will ever yield universal coverage or even come close. Indeed, the late 1990s may turn out to have been the high-water mark for health insurance coverage within the parameters of the current system.

Decades of experience show that major progress in covering the uninsured will require a substantial new investment by the federal government. Heavy reliance upon state financing, on top of large differences in employer coverage, is the primary reason for dramatic interstate variations in coverage and, ultimately, for the large gaps in coverage that remain. While states have substantial financial capacity, that capacity is more limited than that of the federal government; it falls with economic downturns, at precisely the same time that health care needs increase; and its funding sources are less progressive than the federal government’s are, making it harder to redistribute funds to services for low-income families.

The challenge for federalism is to devise a financing role for states that continues to prompt administrative innovation while minimizing the inequities that arise when they must bear an overwhelming fiscal burden. Our two approaches take different paths toward striking this balance. The first retains a large role for states; the second diminishes that role. Both would maximize the base of coverage and provide opportunities for moving beyond it while encouraging innovation and experimentation. Neither approach eliminates interstate variation or the inequities it implies. However, since both start from a higher coverage base, the inequities are more defensible than are those in the current system.

Proposals that require substantial new federal funding could be unrealistic in the current fiscal climate. However, without additional federal funds, the states are unlikely to sustain their current coverage levels, let alone increase them. Changing the balance of federalism involves risk. However, there is no other way to return stability and sustainability to our system so that we can build upon it to greatly reduce the number of uninsured Americans.

http://www.healthaffairs.org/WebExclusives/Holahan_Web_Excl_071603.htm

Comment: Although this article discusses federalism and health policy for low-income individuals, the general concept can apply to our entire health care system. Moderate-income individuals are now faced with inadequate benefits, excessive cost sharing, unaffordable premiums, uninsurability because of preexisting disorders, the burden of cost shifting, and all of the other inequities that characterize our system.

John Holahan and his colleagues explain why major federal funding is essential for state health care programs for low-income populations. The single payer model of reform calls for federal funding with state administration, but for everyone. The concept of federalism in health policy should be expanded to accommodate the single payer model which would address the inequities that we all currently face.

On July 20, “Federalism and Health Policy,” a book by these authors will be available from the Urban Institute Press:

http://www.uipress.org/Template.cfm?Section=Browse_by_Author&Template=/Ecommerce/ProductDisplay.cfm&ProductID=4263