One Single Solution

Editor's note: What follows is an abridged version of the proposal published in the August 13, 2003, issue of the Journal of the American Medical Association, "Proposal of the Physicians' Working Group for Single-Payer National Health Insurance," Vol. 280, No. 6, pp. 798-805.

For nine decades, opponents have blocked proposals for national health insurance, touting private sector solutions. Their reforms over the past quarter century have emphasized market mechanisms, endorsed the central role of private insurers, and nourished investor-ownership of care. But vows of greater efficiency, cost control, and consumer responsiveness are unfulfilled; meanwhile the ranks of the uninsured have swelled.

Many in today's political climate propose pushing on with the marketization of health care. They would shift more public money to private insurers; funnel Medicare through private managed care; and further fray the threadbare safety net of Medicaid, public hospitals and community clinics. These steps would fortify investors' control of care, squander additional billions on useless paperwork, and raise barriers to care still higher. It is time to change fundamentally the trajectory of America's health care - to develop a comprehensive National Health Insurance (NHI) program for the United States.

Four principles shape our vision of reform:

• Access to comprehensive health care is a human right. It is the responsibility of society, through its government, to assure this right. Coverage should not be tied to employment. Private insurance firms' past record disqualifies them from a central role in managing health care.
• The right to choose and change one's physician is fundamental to patient autonomy. Patients should be free to seek care from any licensed health care professional.
• Pursuit of corporate profit and personal fortune have no place in caregiving and they create enormous waste. The U.S. already spends enough to provide comprehensive health care to all Americans with no increase in total costs. However, the vast health care resources now squandered on bureaucracy (mostly due to efforts to divert costs to other payers or onto patients themselves), profits, marketing, and useless or even harmful medical interventions must be shifted to needed care.
• In a democracy, the public should set overall health policies. Personal medical decisions must be made by patients with their caregivers, not by corporate or government bureaucrats.

We envision a national health insurance program (NHI) that builds on the strengths of the current Medicare system. Coverage would be extended to ll age groups, and expanded to include prescription medications and long-term care. Payment mechanisms would be structured to improve efficiency and assure prompt reimbursement, while reducing bureaucracy and cost shifting. Health planning would be enhanced to improve the availability of resources and minimize wasteful duplication. Finally, investor-owned facilities would be phased out. These reforms would shift resources from bureaucracy to the bedside, allowing universal coverage without increasing the total costs of health care.

Key Features

Eligibility Coverage A single public plan would cover every American for all medically necessary services including: acute, rehabilitative, long term and home care, mental health, dental services, occupational health care, prescription drugs and supplies, and preventive and public health measures. Boards of expert and community representatives would assess which services are unnecessary or ineffective, and exclude them from coverage. As in the Medicare program, private insurance duplicating the public coverage would be proscribed. Patient co-payments and deductibles would also be eliminated.

Hospital Payment The NHI would pay each hospital a monthly lump sum to cover all operating expenses -- that is, a global budget. The hospital and the NHI would negotiate the amount of this payment annually, based on past expenditures, previous financial and clinical performance, projected changes in levels of services, wages and input costs, and proposed new and innovative programs. Hospitals would not bill for services covered by the NHI.

Payment for Physicians and Outpatient Care The NHI would include three payment options for physicians and other practitioners: fee-for-service; salaried positions in institutions receiving global budgets; and salaried positions within group practices or HMOs receiving capitation payments. Investor-owned HMOs and group practices would be converted to not-for-profit status. Only institutions that actually deliver care could receive NHI payments, excluding most current HMOs and some practice management firms that contract for services but don't own or operate any clinical facilities.

Long-Term Care The NHI would cover disabled Americans of all ages for all necessary home and nursing home care. Anyone unable to perform activities of daily living (ADLs or IADLs*) would be eligible for services. Since most disabled and elderly people would prefer to remain in their homes, the program would encourage home and community based services.

Capital Spending, Health Planning, and Profit Funds for the construction or renovation of health facilities, and for major equipment purchases would be appropriated from the NHI budget.

Medications and Supplies NHI would pay for all medically necessary prescription drugs and medical supplies, based on a national formulary. An expert panel would establish and regularly update the formulary.

Funding NHI would disburse virtually all payments for health services. Total expenditures would be set at approximately the same proportion of the Gross National Product as in the year preceding the establishment of NHI.

Comment Under an NHI program, the financial threat of illness to patients would be eliminated, as would current restrictions on choice of physicians and hospitals. Taxes would increase, but except for the very wealthy, would be fully offset by the elimination of insurance premiums and out-of-pocket costs. Most important, NHI would establish a right to health care.

Clinical decisions would be driven by science and compassion, not the patient's insurance status or by bureaucratic dictum.

Conclusion

Health care reform is again near the top of the political agenda. Health care costs have turned sharply upward. The number of Americans without insurance or with inadequate coverage rose even in the boom years of the 1990s. Medicare and Medicaid are threatened by ill-conceived reform schemes. And middle class voters are fed up with the abuses of managed care. Incremental changes cannot solve these problems; further reliance on market-based strategies will exacerbate them. What needs to be changed is the system itself.