Governor's Newsletter, Fall 1999

From the Governor's Corner

For the past two decades, the United States has experienced an unprecedented period of economic growth and prosperity. One of the most troubling ironies during this period is that the number of U.S. citizens without health insurance has actually increased an appalling 15% over the past five years to 43 million. This represents 18.2% of the total population. Things are even worse in Georgia where there are an estimated 1.138 million citizens, or 19.3% of the state's population, with no health insurance. Our lack of political will to face this problem as a nation and address it is troubling. Physicians, who are the principle providers of health care to our nation's citizens, need to play a key role in properly addressing this national crisis. The new ACP-ASIM president, Dr. Whitney W. Addington, has made universal access to quality and affordable health care insurance "the rock" on which his term of office will be built.

Currently, the ACP-ASIM is taking a two pronged approach to this problem. The first effort is a proposal to immediately address the most vulnerable group of uninsured Americans; those with incomes between 101-150% of poverty level. This incremental proposal calls for Congress to commit funds equal to 12.6% of the projected federal budget surplus over the next five years to expand access to coverage. These funds will be targeted in four areas to help low to moderate income citizens obtain health insurance coverage.

The first area is a refundable tax credit for uninsured Americans whose income falls between 101-150% of poverty level. This credit will be administered with an advance payment option so enrollees will be able to receive monthly payments to offset the insurance premium cost rather than wait until their taxes are filed to obtain credits. The second recommendation is to expand Medicaid coverage to provide coverage to all Americans with incomes up to 100% of poverty level. The third proposal is to expand funding for Medicaid enrollment outreach designed to make eligible citizens aware of their eligibility for coverage under Medicaid. Finally, the fourth proposal is to provide federal subsidies for temporarily unemployed and uninsured persons to obtain coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) program. The subsidies would enable the unemployed individuals to continue for 18 months to pay the premiums for the group insurance which they previously had while employed. The College projects that if 12.6% of the expected federal budget surplus were used to enact these four proposals, Congress would provide coverage for up to 10.5 million additional Americans.

The second key initiative of the College to address the need for universal health care coverage is its "Decision 2000" campaign. This long term initiative is an effort to put the goal of universal health care at the center of the 2000 presidential and congressional election campaigns. The campaign's goal is to have every presidential and congressional candidate take a pledge to address the problem of uninsured Americans within his or her first year of taking office, and develop a plan to provide universal health care insurance coverage by the end of 2001.

These two initiatives are very ambitious, but also very achievable. I think such efforts speak to the high caliber of leadership and professionalism that pervades this College. With the support of all of our College members, I believe we can prevail in addressing this important national problem. Two of our Chapter members, who have done a lot of thinking about this problem, offer their perspectives. Dr. Evan Weisman is a Cardiologist in Marietta, Georgia, and is Co-Chair of the Health and Public Policy Committee for our Chapter. Dr. Glenn Carter is an Internist in Hinesville, Georgia, and is currently Vice-President of the Chapter. I believe that their differing perspectives reflect the complexity of the issue. Perhaps, more important than one's particular perspective is one's willingness to get involved and help find a solution.

Healthcare in the United States

The Case For a Single Payer System
By: Evan Weisman, MD, FACP

The American College of Physicians advocates universal access to health care for all Americans, a laudatory but increasingly elusive goal. The ranks of the uninsured and underinsured grow at a rate of 125,000 per month. American physicians are increasingly frustrated by an incredibly complex and onerous "health care system" that parasitizes our health care budget and diminishes our autonomy and professionalism. A single payer system would provide all Americans access to basic health care and allow American physicians to participate in a system in which the bottom line is patient care, not profits.

A single payer system (e.g., the Canadian health care system) is not "socialized medicine." Socialized medicine implies governmental control of all aspects of health care delivery. A single payer system would make the government responsible for one function - remuneration. Negotiations among the payers, providers and beneficiaries would determine that level of remuneration.

A single payer system would provide the following:

  1. Universal coverage (no more uninsured).
  2. Unrestricted choice of doctors (no panels).
  3. Independent doctors.
  4. Basic benefit package including prevention, long term care, and mental health.
  5. Disconnecting the link between employment status and access to health care. After World War II, employers offered health insurance as an inexpensive benefit to attract workers. This has become an albatross of American business interests and has reduced their competitiveness. No other nation depends on its business community to finance health care.
  6. No further private health care insurance (let insurance companies make their profits elsewhere.)
  7. Huge reductions in administrative costs (2% for Medicare and 13% for private insurers.)

The anecdotal arguments that Canadians have unacceptable waiting periods might pertain to elective procedures (average waiting time for knee replacement was eight months in Ontario compared to three weeks in the U.S. - but patient satisfaction levels for the procedure and the care are identical.) On the other hand, there is no significant waiting period for urgent procedures (e.g., coronary artery bypass surgery.)

Canadians like their system (96% preferred theirs to ours.) Canadian doctors prefer their system (85% preferred theirs to ours.) While American physicians are discouraging their children from entering the profession and medical school applications in the U.S. dropped for the second straight year, this is not the case in Canada.

America has the financial resources to support a single payer system. As of 1997, health care spending averaged $4005 for every U.S. citizen compared to $2200 in Canada. As of 1995, the U.S. spent 14% of its GNP on health care. Canada spent 9%. Administrative health care costs in Canada were one-fourth that of the U.S. In addition, we already have large numbers of competing inpatient and outpatient facilities that are already in place and are underutilized. Of course, the generous tax incentives that are currently provided to business to finance American health care will be removed and will provide substantial revenue for a single payer system. Finally, the costly emergency room and other currently unremunerated forms of medical care will be eliminated.

A recent survey in the New England Journal of Medicine reported that 57% of medical students, residents, and faculty favored a single payer system. The percentage preferring managed care and fee for service was in the low 20s (with fee for service last.) If more physicians supported the single payer solution, it would restore our prestige and permit us to practice in a far more ethical and professional atmosphere. How refreshing it would be if we physicians provided the leadership for meaningful health care reform.

The Case For a Fee For Service Model
By: Glenn Carter, MD, FACP

The healthcare system in the United States is the best on the planet. Patients from all over the globe come to our country for medical advances. The free enterprise system given to us by our forefathers has allowed medical advances that could not have been imagined by other countries. Pharmaceutical companies have spent billions of dollars on research that has yielded new products. Our medical centers provide the best education available and offer the environment where medical advances are made everyday.

Over the past few years, much criticism has been made about the U.S. healthcare system. The cost has gone up significantly with the insurance industry getting major amounts of the blame. Health insurance costs have gone up exponentially. Likewise, utilization of medical advances by patients insisting on doing everything possible continues unabated. More U.S. citizens are finding health insurance unaffordable, and the number without health insurance has risen above 40 million.

Increasingly, the clamor has been to make healthcare a right. Most people who feel this way don't actually want to spend their tax dollars on someone else. For years, hospitals were allowed to charge $2.00 for aspirin and use the excess to provide healthcare for those who "fall through the cracks." That was fine until the government, in its infinite wisdom, stopped allowing hospitals to transfer patients to the medical centers and began requiring the "same level of care" to everyone, including MRI's, etc. Most physicians will defend their practice of medicine, but expensive tests manage to get "put off" and expensive prescriptions manage to not get filled or to be replaced with less expensive alternatives.

Up to now, one might think I would be in favor of a major revamp of our medical care system. You would be correct. However, rather than replacing it with a single payer system, I would expand the fee for service model and encourage the U.S. government to find a way to minimize, rather than maximize, its involvement. We need a new funding mechanism for our medical centers which would allow them to return to their primary mission of training the finest medical professionals in the world. We need to expand the use of medical saving accounts, which encourage citizens to utilize healthcare only when needed, and give them an opportunity to share in financial benefits if successful.

Single payer systems can and do work. A majority, 50+ percent, of patients in Canada are satisfied. However, Canadian citizens come across the border in droves to get American medical care - medical tests and surgery without the wait. The majority of U.S. citizens who want everything now - the McDonald's generation - will not accept a single payer system.

Uncle S.U.M. (Summer Undergraduate Mentoring) Wants You

In 1998, the Georgia Chapter ACP-ASIM started a four week summer mentoring program to interest medical students early in their training in the field of Internal Medicine by allowing them to work with practicing internists around the state. The program has been a huge success.

To expand the capacity and funding of the program, the Georgia Chapter joined with the Georgia Academy of Family Practice, which has had a similar program, and placed both programs under the oversight of the Georgia Board for Physician Workforce. This move allowed us access to state funds for the program, and thus expand the number of medical students who could participate. Dee Hanson, the Executive Director of the Georgia Board for Physician Workforce, has long been involved with primary care development in Georgia and has been extremely interested in getting more internists involved. Among the physicians sitting on the board is our own Dr. Robert Copeland, so the College and our Chapter are being well represented.

Our biggest need for continuing this vital program is getting more volunteer internists willing to work with these medical students. During this past 1999 summer, more medical students were interested in working with internists than there were internists willing to serve as mentors. This meant one of two things - either they were diverted to the family practice mentoring program, or worse, they are completely denied the opportunity to work with a primary care physician.

Taking care of patients with complex medical illnesses is not going to become any less challenging in the future. We need to continue to attract the highest caliber medical students into our professional specialty. Please consider enrolling as a mentor by calling Dee Hanson or Donna Brantley at (404) 352-6476. No extra training is required. Your presence and the experience of your patients will provide the experience of a lifetime for these students.

Leadership Day

Leadership Day on Capitol Hill took place May 25 and 26. Our Chapter was represented by Sandy Fryhofer, who is also President-Elect of the ACP-ASIM; Bill Grow, Co-Chair of our Chapter Health and Public Policy Committee; Janice Herbert-Carter, member of our Governor's Council; and myself. We were able to speak with Senator Max Cleland and House of Representatives Johnny Isakson, Saxby Chambliss, John Lewis, Sanford Bishop and Charlie Norwood. All of these elected officials and their staff showed keen interest in our viewpoints. Even better, we also had free access to all the Georgia peanuts and Coca-Cola we wanted. It just does not get any better than that.

The main issues we addressed included the College's tax credit plan to cover health insurance costs for low to moderate income uninsured Americans, electronic medical records confidentiality, patients' Bill of Rights (Charles Norwood is playing a very key role in this major issue), the decline in federal funding for graduate medical education, plans for restructuring Medicare, collective bargaining for physicians and firearm injury prevention.

For an in-depth look at these issues and the College's position on them, log on to the ACP-ASIM web site . If you are interested in working on some of these issues, our Health and Public Policy Committee could use your support. Contact Bill Grow at (912) 244-9095 or Evan Weisman at (770) 427-1307.

Member Milestones

Mark Skillan, MD, ACP-ASIM Member from Atlanta, was recently named Chairman of the American Council of Life Insurance, Medical Section, at the Section's Annual Meeting in Santa Barbara. The ACLI, Medical Section, is a professional and continuing medical education organization for physicians who are Medical Directors or Consultants for life, disability and long term care insurance companies. There are more than 400 physician members, most of whom are Internists. The UCLA School of Medicine presented this year's academic session.

Mark completed medical school at UAB and medical residency and chief residency under John Cantwell, MD, at Georgia Baptist Medical Center, now Atlanta Medical Center. He is Board Certified in Internal Medicine. He serves as Vice President and Medical Director of the Munich American Reassurance Company and is a staff physician and Medical Director for Ashton Woods Rehabilitation Center in Atlanta.

Georgia Chapter Governor

Joseph W. Stubbs, MD, FACP
Albany Internal Medicine PC
425 Third Avenue, Suite 300
Albany, GA 31701
Telephone: (912) 483-2000
Fax: (912) 483-2093
E-mail: jstubbs@surfsouth.com

What's New

Contact Information

Vincent Nicolais, MD, FACP,
Governor, Georgia Chapter

Karen Townsend
Executive Director
Ph: 770-693-9973
Georgia Chapter

Michelle Dietz
Administrative Assistant
Ph: 770-920-6995