A Better-Quality Alternative: Single-Payer National Health System Reform
Reprinted from JAMA The Journal of the American Medical Association September 14, 1994, Volume 272 Copyright 1994, American Medical Association.
From the Division of General Medicine/Primary Care, Cook County Hospital, Chicago, Ill (Dr Schiff); the Division of General Internal Medicine and the Institute for Health Policy Studies, San Francisco General Hospital, University of California-San Francisco (Dr Bindman); and the Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (Dr Brennan). Dr Bindman is a Robert Wood Johnson General Physician Faculty Scholar.
A complete list of the members of the working group that drafted this report, which was then reviewed and endorsed by Physicians for a National Health Program, a national organization representing more than 6000 physicians, appears at the end of this article.
Reprint requests to Physicians for a National Health Program, 29 E. Madison St., Suite 602, Chicago, IL 60602 (Dr Schiff).
MANY MISCONSTRUE US health system reform options by presuming that "trade-offs" are needed to counter-balance the competing goals of increasing access, containing costs, and preserving quality.1, 2 Standing as an apparent paradox to this zero-sum equation are countries such as Canada that ensure access to all at a cost 40% per capita less, with satisfaction and outcomes as good as or better than those in the United States.3, 4 While the efficiencies of a single-payer universal program are widely acknowledged to facilitate simultaneous cost control and universal access, lingering concerns about quality have blunted support for this approach.
Quality is of paramount importance to Americans. Opponents of reform appeal to fears of diminished quality, warning of waiting lists, rationing, and "government control."5 Missing from more narrow discussions of the accuracy of such charges is a broader exploration of the quality implications of a universal health care program. Conversely, advocates of national health insurance have failed to emphasize quality issues as key criteria for reform,6 often assuming that we have "the best medical services in the world."7 They portray reform primarily as extending the benefits of private insurance to those currently uninsured, with safeguards added to pre- serve quality.
We disagree with both views. It is unthinkable to label our current system as "highest quality" given its frequent failure to provide such basic services as immunizations or prenatal, primary, and preventive care. Moreover, there is growing concern about quality problems with the care that is provided. Quality problems in the current system include denial of care, discrimination,8 disparities, geographic maldistribution,9 lack of continuity, lack of primary care,10 inadequate or lack of prenatal care,11 failure to provide beneficial prevention,12 substandard/incompetent providers,13 declining patient satisfaction and impersonal care,14,15 iatrogenesis (negligent adverse events),16 diagnostic errors,17 unnecessary procedures/surgery,18 sub-optimal medication prescribing/usage,19 and neglect of quality-of-life/psychosocial issues.20 Our "highest-quality" complacency is especially challenged by insights from two seemingly disparate sources: (1) epidemiologic research based on financial claims databases and (2) industrial quality improvement concepts pioneered in Japan. These two sources converge around the concept of "variations," illuminating widespread differences in clinical practice, further challenging the cost-access-quality trade-off assumption. Data and insights from these two new paradigms demonstrate that better care will actually cost less once improvements are made in care processes and clinical decision making.21,22
The health system must work better to extend access and to control costs. In this article, we argue that a single-payer national health program provides a better framework for improving quality. First, we briefly review requirements for quality care. Then, we propose 10 principles that should be integral to reform strategies to augment quality. We contrast our approach with the current managed competition strategy,23 showing how a single-payer system is more likely to facilitate these 10 interrelated quality features.
WHAT IS QUALITY? HOW CAN IT BE MEASURED?
High-quality care should result in improved health for individuals and the entire community. It depends on knowledgeable, caring providers who have a thorough understanding of preventive, diagnostic, and therapeutic strategies and the link between their application and improved health outcomes. Such strategies need to be applied with the highest technical skill and carried out in a humane, culturally sensitive, and coordinated manner. Quality will suffer when any of these components is lacking.
There is no single gold standard measurement of health care quality; its assessment requires multiple perspectives. The care provided to the population as a whole as well as to individual patients should be evaluated because critical quality issues may affect individuals who do not have access to medical services. Viewpoints of providers, patients, family members, and the community must be incorporated. Evaluated services should not be limited to medical care but should also include related services, such as nursing services, social services, and community education. To judge quality, we need a lengthened time frame that allows not only for examination of longer-term impacts but also for changes over time in what is considered good care. Finally, quality should be judged in the context of costs, because when equally good care is provided at a lower cost, more resources are available for other services.
Although consensus has emerged around many of these precepts,24,25 there is disappointment over the extent to which their fragmented application has actually improved care.26,27 This meagerness of demonstrated benefit is especially worrisome given providers' frustration with the time and administrative burdens imposed by current oversight measures. Promising efforts to operationalize these precepts on a larger scale (ie, Agency for Health Care Policy and Research, the Joint Commission on Accreditation of Healthcare Organizations' Agenda for Change, and Medicare's Quality Improvement Initiative)28 will continue to have limited success if not linked to more fundamental changes in health care finance and delivery. This will require health system reform based on the application of quality assurance tools and insights, guided by the principles outlined below.
TEN PRINCIPLES FOR IMPROVED QUALITY
1. There is a profound and inseparable relationship between access and quality: universal insurance coverage is a prerequisite for quality care. Because quality must be population based, traditional definitions of quality should be broadened to include the gravest of quality deficits-denial of care.28 The most important prerequisite for access is health insurance. To delay universal coverage for years, as projected in the Clinton plan and various congressional health proposals, means the continuation of compromised quality for millions of people.
Growing evidence from large observational studies underscores this strong relationship between quality and access/ insurance status:
- The hospitalized uninsured are 2.3 times more likely to suffer adverse iatrogenic events.29
- The loss of Medicaid coverage has been associated with a 10-point increase in diastolic blood pressure and a 15% increase in the hemoglobin A1c level in diabetic patients, increasing the odds of dying within 6 months by 40%.30
- The uninsured poor are twice as likely as those with private insurance to delay hospital care; among those delaying care, hospital stays are longer and death rates are higher.31
- Being uninsured was associated with twice the 15-year mortality (18.4% vs 9.6%); even after adjusting for major health risk factors, mortality remained 25% higher.32
- Lack of health insurance is associated with failure to receive preventive services, including blood pressure monitoring, Papanicolaou tests, breast examinations, and glaucoma screening.33
This profound connection between quality and access extends far beyond simply underserving the uninsured. Access problems threaten quality for those with insurance who encounter delays and overcrowding in emergency departments overflowing with patients lacking primary care.34 For the insured, limitations on benefits, including financial barriers (such as co-payments, restrictions in coverage, and rationing via administrative obstacles), increasingly obstruct care.35 Most important, quality is distorted when ability and willingness to pay become the criteria for determining which services are provided. Marginally effective or even harmful treatments for the well-insured affluent take priority over more needed and appropriate services.36
2. The best guarantor of universal high-quality care is a unified system that does not treat patients differently based on employment, financial status, or source of payment. This principle embodies Eddy's health care "golden rule": If a service is necessary for oneself, it is necessary for others.37 We reject the notion that different people are entitled to a different quality of care.
The quality-impairing consequences of separate classes of insurance are illustrated by Medicaid, whose recipients, though "insured," are often refused care or provided substandard treatment.38 For many medical services, access for Medicaid patients is little better than for the uninsured (D. U. Himmelstein and S. Woolhandler, unpublished tabulations from the 1987 National Medical Expenditures Survey). Similarly, universally available lowest-tier coverage, such as that proposed under managed competition, with more or better services only for those able to afford to upgrade their benefits, violates this principle and would perpetuate inequalities in health care.
The equality principle is a prerequisite to grapple meaningfully with ways to control marginally effective expensive interventions. Otherwise, limits based on ability to pay are, by definition, discrimination against the poor.39
Under a multitiered system, patients and providers internalize an "everyone for himself or herself' ethic, eroding incentives for improving the system overall.40 A cohesive system based on fairness and equality could harness each citizen's desires for quality care to drive system quality upward. It would promote mechanisms for individual complaints to be linked to system-wide improvement rather than dissipated as special privileges. It would ensure that the quality of the basic plan is high enough to be acceptable to all citizens. Proposals that allow individual or corporate "opting out" of publicly defined benefit packages erode this quality-enhancing covenant. Hence, a single program not only minimizes discrimination against the vulnerable but also promotes improvement overall.