JAMA: Strategies for implementing universal health care
explored
Commentaries discuss philosophies and ideologies framing the health
care reform debate while proposing implementation strategies for
universal health care.
The health care reform debate continues to rage , as Obama’s
administration works toward the ultimate goal of universal health care
coverage for all Americans. It’s a concept that, while having
worked in multiple industrialized countries, has its share of detractors
where American implementation is concerned—free-market advocates
who claim that government intervention will stifle innovation, lower
quality, and drive up costs—as well as avid supporters, whose
methods for bringing about universal coverage] sometimes do not agree on
underlying philosophy, sources of financing, and what role the
government should play.
Two recent articles in JAMA discuss the issue and offer
direction; one, by David Ortenlicher, proposes three basic
principles for universal coverage which he suggests are requisite for a
successful outcome. The other, co-authored by Troyen A. Brennan and Michelle M.
Mello, discusses the recently favored idea of a two-pronged approach
to health care reform: (1) making Medicare available to all
citizens; and (2) strengthening public oversight of the small-group and
individual insurance markets through a Massachusetts-style
“connector.” According to the article, this “one-two
punch” approach to reform allows market competition, and, as a
result may be more politically viable than fundamental reform has been
in the past.
Ortenlicher proposes that payroll taxes should form the base funding
for a coverage plan. He goes on to compare the earned-income tax credit
versus welfare; the former having enjoyed considerable popular support
while the latter has had negative connotations of
“handouts.” Second, he stresses that a successful universal
plan must be federal-only in its administration, using Medicaid and
failed housing projects as rationale. “With reimbursement rates
under Medicaid well below those under Medicare,” he writes,
“Medicaid recipients experience much greater difficulty than
Medicare recipients in finding a physician to provide care. While
Medicare provides coverage for virtually all seniors, Medicaid reaches
less than half of the indigent.” Public housing, Ortenlicher
asserts, also serves to illustrate a failed federal-state partnership.
As responsibility for site selection shifted to local housing agencies,
they chose to place the housing primarily in inner-city locations due to
pressure from middle-class neighborhoods, and these projects ended up
having to be torn down. Lastly, he stresses that all individuals must
obtain coverage in the same way; a plan in which some are offered the
option of private, employer-based insurance while others use the new
federally funded plan will fail.
Brennan, a physician–attorney with CVS Caremark, and Mello
first address the basic reasons motivating the American shift in the
direction of universal health care reform. While they cover the commonly
known reasons (that the health care status quo fails to provide
reasonable access, delivers relatively poor-quality care, and costs far
more than other health care systems), they also discuss the problem of
cost-control. A new reform approach that would address cost control
would be to combine the relative strengths of Medicare and private
insurance competing across the same risk pools. They caution that such
an approach would require careful selection of those risk pools and some
new regulation similar to those adopted by Massachusetts. That
regulation’s policy neatly aligned the interests of clinician and
insurer lobbyists, Republican bureaucrats, and universal-access
advocates; it took new regulation of the small-group and individual
markets, converted the money in the uncompensated-care pool into subsidy
funding so the uninsured could purchase insurance, and developed a new
federal waiver, thereby bringing the additional funds needed to provide
Medicaid rate increases for private hospitals and physicians.
While exact ways of enacting universal coverage remain up for debate,
the discussion itself is an encouraging step toward the goal of
affordable, accessible, and accountable health care for all
Americans.
Related resources on www.pharmacist.com
Beth Farnstrom (bfarnstrom@aphanet.org)
Posted May 7, 2009, 7:00 am EDT
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