American College of Physicians
Annals of Internal Medicine
January 1, 2008
Position Paper
This issue contains a 3-part article about improving health care in the United States. Unlike previous highly focused policy papers by the American College of Physicians, this article takes a comprehensive approach to improving access, quality, and efficiency of care. The first part describes health care in the United States. The second compares it to health care in other countries. The concluding section proposes lessons that the U.S. can learn from these countries and recommendations for achieving a high-performance health care system in the United States.
Lessons from Other Countries and ACP Recommendations for Redesigning the U.S. Health Care System
Recommendation 1a: Provide universal health insurance coverage to assure that all people within the United States have equitable access to appropriate health care without unreasonable financial barriers. Health insurance coverage and benefits should be continuous and not dependent on place of residence or employment status. The ACP further recommends that the federal and state governments consider adopting one or the other of the following pathways to achieving universal coverage:
- Single-payer financing models, in which one government entity is the sole third-party payer of health care costs, can achieve universal access to health care without barriers based on ability to pay. Single-payer systems generally have the advantage of being more equitable, with lower administrative costs than systems using private health insurance, lower per capita health care expenditures, high levels of consumer and patient satisfaction, and high performance on measures of quality and access. They may require a higher tax burden to support and maintain such systems, particularly as demographic changes reduce the number of younger workers paying into the system. Such systems typically rely on global budgets and price negotiation to help restrain health care expenditures, which may result in shortages of services and delays in obtaining elective procedures and limit individuals’ freedom to make their own health care choices.
- Pluralistic systems, which involve government entities as well as multiple for-profit or not-for-profit private organizations, can assure universal access, while allowing individuals the freedom to purchase private supplemental coverage, but are more likely to result in inequities in coverage and higher administrative costs (Australia and New Zealand). Pluralistic financing models must provide 1) a legal guarantee that all individuals have access to coverage and 2) sufficient government subsidies and funded coverage for those who cannot afford to purchase coverage through the private sector.
http://www.annals.org/cgi/content/full/0000605-200801010-00196v1
Comment:
By Don McCanne, MD
The American College of Physicians agrees that there are really only two options, though they are both government solutions: (1) an efficient, single payer national health program, or (2) a more expensive, administratively complex, inefficient, highly regulated and heavily subsidized fragmented system of a multitude of private plans plus public programs, with means testing and mandates to participate. It doesn’t seem like a difficult choice.
At least we’ve removed from the table the option of waiting for reform from private plans competing in the marketplace. After decades of leaving them in charge we are left with the highest costs and poorest coverage, while falling far short of a high-performance system.
This position paper discusses several other important concepts such as the need for a patient-centered medical home for everyone. The entire paper should be downloaded to use as a resource in your reform efforts.