Universal coverage remains a big deal

Recently JAMA published a special theme issue on critical issues in U.S. health care. Among the contributors was Dr. Ezekiel Emanuel, the oncologist, bioethicist and former White House adviser on health policy.

In his article, “Going to the Moon in Health Care: Medicine’s Big Hairy Audacious Goal (BHAG),” Emanuel argues that contemporary medicine is in need of vision, an overarching, aspirational goal “like going to the moon that can make an organization — or a nation — stretch beyond what it thought was possible to achieve remarkable things.”

He asserts that medicine has no such vision today. In the past, medicine’s BHAG was universal coverage, but now, he suggests, that’s passé.

The goal of universal coverage may have been “transformative for the U.S. polity but not really for the U.S. health system,” he writes. “The Affordable Care Act may result in universal coverage, but that goal no longer has the qualities of a BHAG.”

We strongly disagree. Universal coverage remains a “Big Hairy Ambitious Goal,” especially in view of official estimates that our nation will still have 31 million uninsured people in 2024.

One has to wonder: When Emanuel argues that the goal of universal care “was not transformative for the U.S. health system,” is he speaking of corporate interests, such as the insurance industry? Clearly he does not mean physicians, a majority of whom now support government action to establish national health insurance, which would assure truly universal coverage.

Offering his own candidate for a winning BHAG, Emanuel proposes the financial goal of capping health care cost increases relative to the GDP, or in his words, “By 2020, per capita health care costs will increase no more than gross domestic product (GDP) + 0%.”

Cost control is indeed a worthy and urgent goal, given that economists are unanimous in predicting that health care costs will continue to rise under the Affordable Care Act. But the remedies that Emanuel has traditionally prescribed for this problem fall far short of what is needed.

In point of fact, a single-payer, government-funded system would be the easiest way to control health care costs — and it would also achieve the appropriate BHAG of universal coverage.

A single payer universal insurance system would control costs by:

  • Eliminating the administrative waste and profiteering associated with insurance companies. Far more of the health care dollar would go to health care, not to advertising, administration, or assuring shareholder profits.
  • Allowing the government to negotiate pricing for medications and services to lower costs.
  • Eliminating the need for the poor and uninsured to seek uncompensated health care from ERs.
  • Facilitating a healthier, more productive work force.
  • Employing global budgeting for hospitals, eliminating the incentives driving their role in health care cost escalation.

Emanuel and others have argued that fee-for-service is the driver of excessive health care costs, but there is scant evidence proving this. Other countries provide universal high-quality coverage under a fee-for-service system and are still able to control health care costs.

Obamacare cannot lead to universal coverage. By maintaining the insurance industry’s role as a middleman, it will serve to ensure that health care costs cannot be reined in without draconian restrictions on needed care.

Emanuel rightly suggests that reining in costs will require focusing on outpatient management of patients with chronic conditions. However, the biggest obstacle to this is inadequate access due to uninsurance and underinsurance, not lack of technological tracking of physiologic indicators.

Both access to care and quality improvement would be much easier in a single-payer system.

Emanuel has reframed the crisis in the U.S. health care system as one of cost instead of the approximately 100 million Americans who lack health insurance or have insurance that does not enable appropriate care, leading to many thousands of deaths per year. We suggest that elimination of this travesty is the most important BHAG for physicians and that the solution is a single-payer system.

Philip Verhoef is critical care physician. Stephen Kemble is an internal medicine physician.

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