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We Must Act on Health Care

By Warren A. Jones

Sunday, June 23, 2002; Page B07 

Health care premiums in the nation's second-largest health plan, the California Employees' Retirement System, are projected to rise a whopping 25 percent next year. The nation's largest health plan, the Federal Employees Health Benefit Program, has been ordered to take a hard bargaining position next year after this year's 14 percent cost increase. Many states are grappling with massive deficits driven by burgeoning Medicaid and children's health programs. Columnist David Broder says that "the health care system is in crisis." As a physician, I am certain of that.

The question now is what to do about it. The American people know we must move beyond incremental fixes. In a CBS News/New York Times poll conducted earlier this year, 57 percent of adults said "fundamental changes" are required in the U.S. health care system. Thirty percent said "completely rebuild it." Only 13 percent said "minor changes are necessary."

Contrast those views with Washington's prevailing wisdom. The mantra is "incremental steps" -- not because incrementalism is the right approach but because it is viewed as the only politically viable one. All the evidence, however, says that it's the wrong approach and that it won't work.

The finest attempt at incrementalism to date -- the State Children's Health Insurance Program (SCHIP) for the working poor -- is unraveling just as some measure of success is being realized. The number of children covered under SCHIP increased 38 percent from 2000 to 2001. But now, in the face of budget deficits, states are adding restrictions and fees while they freeze or reduce enrollment. One governor's spokesperson said candidly, "Unless we rein in this very generous program . . . it's going to bust our budget and force a tax increase."

During the longest economic expansion in U.S. history, in the 1990s, health care cost increases were temporarily moderated, and a tight labor market should have incrementally reduced the ranks of the uninsured. Instead, the number of Americans without coverage grew from 35 million to 39 million. Now health care costs are soaring again. It's estimated the economic slowdown has pushed the number of uninsured to more than 40 million, and continuing increases in health care costs will only raise that number higher.

Incrementalism won't work, because the problems are systemic. Reducing the ranks of the uninsured by a million or 2 million is a short-term victory in human terms. But adding them into a broken health care system is a long-term strategy doomed to fail.

This system must be overhauled. Any successful plan will require that everyone be covered -- so we can reduce the huge hidden cost we are all paying in emergency rooms, neonatal intensive care units and all the other places where the uninsured wind up getting care. Just because one attempt at comprehensive reform failed in the early 1990s is no reason to say it cannot be done. It must be done. It's time for new approaches.

The Academy of Family Physicians has a plan to fundamentally restructure the system. It's called Assuring Health Care Coverage for All, and it is based on three principles:

• Basic health care services and protection against catastrophic costs to be guaranteed to everyone. Basic health services are defined as those most likely to be used by most people and services that should be used by all people to prevent illness and disease. Catastrophic coverage would protect the man who had the heart attack from bankruptcy. Bottom line -- all Americans could get the preventive care they need to stay as healthy as possible. Fewer little problems would become big ones. Primary care would be delivered cost-effectively in doctors' offices for approximately 51 percent less than the cost in emergency rooms. People would be protected when sick or injured.

• Health care to be funded through a national, broad-based taxing mechanism. Everyone benefits, and everyone shares the expense.

• The current insurance market to be maintained, including employer-based and individually purchased insurance. People will have the choice to opt out of coverage for services above the basic benefit but below the threshold for catastrophic protection.

Americans know it's time to act. Let's get to the hard discussion about how to do so as quickly as possible. Our proposal is on the table. We are ready to debate the issue and work with others toward a solution.

The writer is president of the American Academy of Family Physicians, representing more than 93,500 family physicians, family practice residents and medical students.

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