The paradoxes of national health reform during the Wilson era

The current debate over health care reform may represent yet another opportunity to establish a national health policy. A similar level of activity occurred during the presidency of Woodrow Wilson. In many ways, the failure to enact national health reform (NHR) in the early 20th Century represents a paradigm for subsequent failed attempts to enact NHR.     

Constitutional guarantees to health care in Spain

This analysis of the Spanish health care system is one in a series of such studies undertaken by the author, following a grid of factors that influence the delivery and financing of health care. The purpose of the national analyses is to facilitate a comparison of the United States' and other health care systems in terms of anticipated reform of the U.S. system. Analyses of the U.S. and nine other national systems are included in a book that has just been published by the College. Spain and nine additional countries will be studied in a book due for publication later this year. A final book with ten additional national analyses will appear in 1996.     

National health insurance--to be or not to be

It has been pointed out by advocates of change in the U.S. health care delivery system that, with the exception of the Republic of South Africa, the United States is the only industrialized nation without a system of national health care. Rising costs and an increasing percentage of Americans without insurance and with limited access to health care services has heightened interest in the development of a mechanism for payment for health care services in this country.     

National health reform advocates retrench and prepare for Medicare

With the failure of President Truman's efforts to pass compulsory health insurance for all, national health reform (NHR) advocates began to redirect their political attention to a politically powerful group of Americans who were simultaneously vulnerable from a health care point of view--the elderly. This effort culminated in the passage of Medicare under President Johnson. This article will focus on antecedents to passage of Medicare that can be found in the Eisenhower and Kennedy administrations. It will also discuss other facets of health reform proposals from the Eisenhower administration. While most proposals never became law, the legislative intent of many of them--outlawing cancellation of policies, a minimum standard health benefit package, establishment of regional health authorities, preference for prepayment plans, and establishment of a reinsurance pool administered by the federal government--is currently under active discussion by the Clinton health reform task forces.     

Physician payment in Canada, Germany, and the United States

As the debate about reforming the U.S. health care system intensifies, interest has focused on three alternative delivery systems: the predominantly private-sector model in the United States, the provincial-government health insurance model of Canada, and the social insurance model of Germany. The organization of physician payment is an important part of all these health care systems. To maintain an affordable system that delivers high-quality care, payment to physicians must be sufficient to attract and maintain an able group of doctors, while not exceeding an amount that the country can afford. In this article, these three systems will be examined, and an attempt will be made to apply the lessons learned from Germany and Canada to the direction of physician payment reform in the United States.     

The consumer choice model: a humane reconstruction of the U.S. health care system

"Consumer choice," "defined contribution health programs," "voucher systems," and "health marts" are variations on a theme: employees buying their own health care. This new approach to health care purchasing, which is designed to minimize the role of employers, is being proposed by an array of economists and by both Republican and Democratic legislators as the best way to address the nation's health care ills. Although enabling national legislation is unlikely to pass soon, the debate will nevertheless change the face of health care in America. The prospect is reminiscent of the debate over "Clinton Care" in 1993--although legislation was never passed, managed care rapidly came to dominate the U.S. health care system. As this reform takes hold, beneficiaries will make their own health plan selections but will have more responsibility and may bear more cost. Providers will have to adapt to new, customer-driven requirements for performance, accountability, and communications but will also find opportunities in a marketplace that they will have a major role in shaping. Physicians, health plans, and insurers should understand how these proposals will transform their role in health care.     

System reform in integrated health systems

As the debate progresses on health care reform and the ultimate form of the U.S. system, important lessons can be drawn from examinations of other health care systems. From the U.S. perspective, European health systems appear to have a certain homogeneity about them. Americans tend to look at all European arrangements as single-source financing systems. Because these systems all provide universal coverage, the assumption is that there must be a strong cohesion and similarity among them. Viewed from the European perspective, the reality appears to be rather different. In this article, the health cae systems of Nordic countries are analyzed in terms of their differences both from other European systems and from the United States approach.     

Defining the health care product to ensure quality and manage costs

The frenzy of health care reform activity now led by the Clinton Administration's American Health Security Act of 1993 might end in the worst of all possible outcomes: a new government entitlement program financed by business and a global budget. Unbridled entitlement could drive utilization of benefits to the maximum and, with a budget cap, guarantee rationing. So far, the administration has talked about expanding access and controlling costs--not about the health care product. Given the threat that change poses for vested interests, time will undoubtedly lapse before final implementation of a new system. Unless physicians involved in health management seize the opportunity during this window of opportunity to help shape the future of health care delivery, the likelihood of preserving the U.S. health care delivery system as we know it will be dim indeed.     

A new perspective on quality

The U.S. health care sector consumes nearly 13 percent of our nation's gross national product, $800 billion annually. Our nation allocates the highest amount per capita to health care in the world. Yet many measures of health care outcomes from these expenditures are inferior to other developed nations. The American health care system costs too much, excludes too many, fails too often, contains much excessive and inappropriate care, and knows too little about the effectiveness of the things it does. The purpose of this article is to discuss current payers' perspectives on the potential for quality improvement in the U.S. health care system.     

Efforts to implement national health reform in the United States

Beginning in this issue and carrying forth during the year, the author will trace the history of the development of a national health policy in the United States. In beginning this new feature, Physician Executive recognizes the potential impact of national health reform on physician executives and the need to contribute to informed discussion on the current national health reform debate. In this first article, the authors sets the stage for the series, establishing the historical precedents for national health care reform and some of the groundrules for the articles to follow.     

Strategic issues requiring public accountability: food for thought

Although the exact outline of U.S. health reform has become fuzzy because of political events, it seems clear that major changes in the manner in which health care is delivered and financed are under way. The initiative for the most part has been assumed by state government and by the health care field itself, as managed care becomes ever more entrenched and the health care system becomes ever more integrated. An expected outcome of these changes will be demands for greater public accountability on the part of health care providers and organizations. In this article, the author discusses some of the issues--professional compensation, documenting community service, ensuring public input into planning efforts, economic credentialing and quality of care, and managing ethics under managed competition--that will have to be addressed at the local level as these shifts take place.     

Research Strategies for Magnetic Fields and Cancer

Widespread concerns about whether electric and magnetic fields (EMF) could adversely affect human health have been raised in epidemiologic studies reported since the 1980s. Possible EMF health effects have been widely publicized in the popular press since that time. We consider here three possible mechanisms of action of EMF on childhood leukemia. We identify the first as "magnetic fields": this hypothesis relates the average level of magnetic field to the incidence of childhood leukemia. We identify a second, recently proposed, mechanism as "contact current": this hypothesis relates the low voltage and consequent current that occurs on the domestic water pipe, due to U.S. grounding practices, as a source for exposure of children. The third hypothesis is that the relationship observed is spurious. Using a modified example taken from the work of Von Winterfeldt and Keeney, we use Decision Analysis to estimate the value of information for distinguishing between the three hypotheses. We believe that this improves on the usual process for deciding on research budgets. Depending on which hypothesis we favor a priori, the value of being informed ranges from US 101 dollars to US 233 dollars per "problem household." Since there could be as many as 2 million such households, the value of information for resolving this issue could approach half a billion dollars! We find that there is no value of information for finding the odds ratio given the contact current hypothesis. In writing this article, we have consciously kept the computations as simple as possible so as to engage the reader's attention and interest. In a penultimate section, we suggest numerous possible extensions for a group interested in discussing and deciding on the value of research on the relationship between magnetic fields and cancer.     

Is the American health care delivery system ready for change?

In October 1992, the American College of Physician Executives sponsored a study tour to Berlin, Germany, and Amsterdam, Holland. Meetings were held with government officials, third-party payers, and providers, and on-site visits were made at hospitals, clinics, and academic centers. The purpose was to study the health care delivery system in those countries and to share some insights with the countries' hosts on the U.S. system. In a series of reports that began in the July issue of the journal, 5 of the 10 study tour participants describe their impressions of the tour and of the health care systems in the countries that were visited. In this final report, the implications of the German and Dutch systems for reform of the U.S. health care system are discussed.     

Reducing health care costs: a case for quality

Today, it is not quality or access but cost that has become the primary motivator for change in the U.S. health care delivery system. Cost, as the driver, has created a frenzy of nationwide activity, searching, examining, and testing any and all ways that offer promise of financial health care stability. And cost, not quality or access, is the principal motivator for the ever accelerating national health care policy debate. But there is a relationship between costs and quality that has to be addressed if quality is to be maintained.     

Truman and the medical profession: replay or lesson for the nineties

This article describes the first serious effort on the part of an American president to enact national health insurance (NHI). President Truman considered his inability to enact NHI the single most important defeat during his presidency. While a variety of factors led to the demise of NHI, three are most notable. The dynamic interplay of these factors, integrated with references to the current accelerating debate over national health reform, will serve as the focus for this seventh article in a series on historical efforts to enact national health reform in the United States.     

The Long‐term Unemployed: A New Protected Class of Employee?

Since the onset of the latest United States (U.S.) recession (beginning in December 2007), the U.S. economy has been posting high unemployment levels consistently exceeding 8 percent. Of specific interest, the U.S. Department of Labor, Bureau of Labor Statistics (BLS), reports on a specific subset of the U.S. unemployed: the long‐term unemployed, defined as those who are unemployed for 27 weeks and over. Since December 2009, the share of the long‐term unemployed of the total U.S. unemployed has exceeded 40 percent (through April 2012), the highest level since 1948 when data was first collected. A phenomenon of this recession is an alleged public bias by American private sector employers against hiring the long‐term unemployed, or even simply those unemployed. While the authors support the removal of discrimination against the unemployed in job advertisements, they cannot support the larger notion of including those who are unemployed as a protected class of employees. Becoming or being unemployed is a state that one can change, and based on the lack of research on how widespread this discrimination is (beyond anecdotal stories or limited research surveys), they believe that extending protection under equal employment opportunity legislation would be overreaching and inappropriate at this time.     

Mandated benefits: a misguided effort

The U.S. Congress is toying with the creation of universally mandated benefits for health care, most specifically in the health care reform proposal offered by the Clinton Administration. The notion of mandated benefits has already become a part of the health care scene in insurance and managed care plans. Instead of benefiting U.S. citizens as a whole, however, mandated benefits are likely to result in a reduction in health care accessibility and quality. The reason is that mandated benefits consume a continuously growing portion of the health care pie. Deming demonstrated that quality brings lower costs, but to obtain quality we must commit adequate resources. The free allocation of resources is negated by mandated benefits.     

Providing children with health care

Introducing a new column on health policy issues of relevance to physician executives. What are the legislative options to provide children with health care coverage? Federal health initiatives for children have become the next frontier in health care reform. This column defines the problem in the U.S., describes voters' support for a federal initiative, and provides discussion of the options available to federal legislators.     

The evolving role of the primary care physician

In today's climate of health care reform, the title of this article might more appropriately be "Is the Role of the Primary Care Physician Evolving or Going the Way of the Dinosaur?" According to Koop, primary care is in trouble. Whereas only 29 percent of U.S. physicians are primary care physicians, in Great Britain, 72 percent of physicians are primary care physicians and in Europe and Canada the average is 50 percent. Many U.S. primary care physicians are in the later stages of their careers and nearing retirement age. Unless the supply increases, this number will dwindle further. However, in 1992, only 14 percent of U.S. medical school graduates were headed for primary care careers. Even if the supply of primary care graduates were increased to 50 percent of the graduating medical school class, it would be well into the next century before the ratio of primary care physicians to specialists would be equal. Primary care is at a critical juncture and the next few years will decide the fate of the primary care physician. Given the state of primary care today, I believe that a fundamental look at the assumptions regarding the role of primary care physicians is in order. The current health reform movement has placed a major responsibility on primary care to solve many of the problems in health care delivery today, such as cost, utilization, and prevention. Many health care organizations are planning strategies involving primary care providers, and physician executives can play a key role in these decisions.     

Demand rising for medicine's rarest birds

The prognosis from most quarters is that the U.S. health care delivery system is moving inexorably toward managed care. The final form that managed care takes under whatever health reform measure finally takes shape in Washington is still in doubt, but it is clear that care will be managed in the future. It also seems increasingly clear that the system evolving will require more primary care providers, and that they will occupy some very key decision-making roles in the clinical firmament. In this article, staff writer Donna Vavala brings together the thoughts and predictions of several health care leaders on this critical topic in medical management.