Posted on December 6, 2004

The Nation Now Wants to Hear From Woolhandler and Himmelstein


Mixed solutions to problem of uninsured
American Medical Association
House of Delegates
Interim Meeting Highlights
Monday, December 6, 2004

About 300 delegates heard details on one of the AMA’s seven agenda items during Sunday’s Forum for Medical Affairs. One of five presenters, John Goodman of the National Center for Policy Analysis outlined HSA advantages, including: restoration of the patient-physician relationship; portability; and patient and physician incentives.

According to Physicians for a National Health Program spokesperson Steffie Woolhandler, MD, the use of tax credits to cover the uninsured, as proposed by the AMA, is “a bad idea. It’s been tried before and it’s failed.” While she doesn’t support the Canadian national system per se, she believes the U.S. system should become “Canada deluxe.”

After congratulating Dr. Woolhandler on her life’s work in researching the uninsured (which brought the crowd to its feet), and noting the obvious differences between hers and the AMA’s proposals, AMA President John C. Nelson, MD, MPH, emphasized the extreme importance of working together to create a comprehensive solution.


The Disparate Consensus on Health Care for All
By Steve Lohr
The New York Times - December 6, 2004

In Washington, the phrase “universal coverage” is rarely mentioned as the way to provide health insurance for the 45 million uninsured Americans. It evokes memories of the Clinton administration’s sobering failure to forge a national health care plan. Yet among health care experts there is a surprising consensus that the United States must inevitably adopt some kind of universal coverage.

…health care experts contend that the issue must be addressed. Their policy proposals vary widely, and the proponents of universal coverage are as different as Dr. William W. McGuire, chief executive of one of the nation’s largest health insurers, and Dr. David Himmelstein of the Harvard Medical School, who recommends eliminating big insurers like Dr. McGuire’s company, the UnitedHealth Group.

Whatever their differences, they do agree that moving toward universal coverage would surely save lives and maybe dollars as well. Any plan for universal coverage must answer at least three basic questions: Will the move to national coverage follow an incremental, step-by-step path or require drastic change? What role will the government play? What should be covered under a universal system?

Dr. Himmelstein, an associate professor at the Harvard Medical School, advocates a fairly sweeping overhaul of health care in America by moving to a single-payer system run by the government. The nation, he said, can no longer afford the costs of bureaucracy in the American system.

Dr. Himmelstein was a co-author of a study last year, published in The New England Journal of Medicine, that found that administrative costs represented 31 percent of total health care spending in the United States, about double the proportion in Canada, which has a single-payer system.

The culprits, in Dr. Himmelstein’s view, are all the middlemen - chiefly insurers - tussling with doctors, hospitals and nursing homes over bills and reimbursements. “Health care has become a spectator sport with this huge, costly bureaucracy watching over us,” he said.

About one million of the workers in the system, Dr. Himmelstein said, are doing unneeded administrative work that could be eliminated. The savings from moving to a single-payer system, he estimated, would be roughly $375 billion a year. “That allows you to cover everyone,” he said.

The single payer, Dr. Himmelstein suggested, would be a pumped-up Medicare with greater buying power to bargain hard with suppliers like pharmaceutical makers, to control drug costs.

Not surprisingly, Dr. McGuire of UnitedHealth opposes the single-payer formula. “The key issue is not who is paying, but what you are paying for,” he said. “I think we should have mandatory insurance. It should be based on the concept of an essential benefit. Guided by medical science, we should decide what is essential and provide it.”

If a person is employed, his or her employer would have to pay for the essential benefit, according to Dr. Maguire. Self-employed people, or others who are financially able, would pay for their own insurance, and for everyone else, the obligation would fall to the federal government or the states.

The thorny issue in an essential benefit program is what is covered and what is not. Shoulder surgery to ease the pain when swinging a golf club or impotence pills should not be considered essential, said Dr. Reed Tuckson, a senior vice president for medical care advancement at UnitedHealth.

It will take political will and some hard choices about what path to take, but the United States certainly has the means to provide health insurance to everyone, health experts say. Neelam Sekhri, a health policy and finance expert at the World Health Organization, illustrates it this way: American government spending on Medicare and Medicaid alone, which covers about 40 percent of the population, if spread across the nation’s entire population, would equal on a per capita basis total spending by most European countries.

From a strictly financial standpoint, Ms. Sekhri said, “Given the amount of money that the United States spends on health, there is no reason why it should not be able to provide a very good system of universal health coverage.”

Comment: Harvard professors Steffie Woolhandler and David Himmelstein were co-chairs of the writing committee that produced the 1989 New England Journal of Medicine article, “A National Health Program for the United States: A Physicians’ Proposal.” They were cofounders of Physicians for a National Health Program (PNHP). Since then they have continued in a leadership role in producing innumerable other reports, research data, articles, restatements of the physicians’ proposal, in addition to their other advocacy activities in support of single payer, national health insurance.

It has sometimes been a thankless task. With the defeat of the unfortunate Clinton attempt at reform, policymakers decided that reform could never be comprehensive but must be in incremental steps. Advocates of universal reform were essentially barred from participation in the forums on reform. Even the progressives, who were previously in support of a universal health program, became fragmented over factional disputes. To the public at large, the movement for a national health program appeared to have wilted and died.

But David and Steffie were not deterred. They led the writing team that produced the 2003 JAMA article, “Proposal of the Physicians’ Working Group for Single-Payer National health Insurance.” They provided irrefutable evidence of the profound administrative waste of our fragmented system of funding health care (2003 NEJM, “Cost of Health Care Administration in the United States and Canada”).

Their colleagues at PNHP became passionate advocates of the single payer model because we recognized the vast superiority over the current system and over other mediocre proposals for reform. We pounded on doors and inserted our foot when opened. We insisted on being part of the debate, even if our presence was not particularly welcome.

Current attempts at reform have failed miserably. Costs continue to escalate, greater numbers are without insurance, and we have a major epidemic of under-insurance with the resultant explosion of financial hardship due to non-covered medical expenses.

The failure of our current system is no longer in dispute. We now hear throughout the nation the resounding chorus calling out for a national solution. Since David and Steffie and the rest of us persevered, we were there when others decided that we need to broaden our perspective on reform. David and Steffie, with the help of colleagues, have shown that we can provide affordable, comprehensive health care coverage for everyone. The policy science is not in dispute. Others are now saying that maybe it is time to take a serious look at the single payer, Medicare for All, national health insurance model.

Today, the American Medical Association and The New York Times affirmed the credibility of David and Steffie and of the single payer model of reform. Although the process has only begun, single payer will now have its rightful place in the national dialogue on reform. In fact, the greater burden in the debate may well shift to the defenders of the status quo since the superiority of the single payer model will speak for itself.

Steffie and David can be very, very proud, as we are of them. I mean… like… Steffie brought members of the AMA House of Delegates to their feet!