Questions and Answers About ACP’s New Evidence-Based Paper and Web Tool to Evaluate Presidential Candidates’ Positions
Achieving a High Performance Health Care System with Universal Access: What the USA Can Learn from Other Countries was authored by ACP’s Health and Public Policy Committee and approved as ACP policy at the October 2007 meeting of the Board of Regents. The paper reflects comments received on an earlier draft from members of the Board of Governors, Board of Regents, ACP Councils, and selected expert advisors.
(to ask other questions, or to take part in a discussion on the paper, go to the discussion area)
Achieving a High Performance Health Care System with Universal Access: What the USA Can Learn from Other Countries
We know that ACP’s 125,000 members count on the College to deliver evidence-based solutions to our country’s many health care problems, including the appalling lack of access to affordable heath coverage, the impending crisis of not having a sufficient supply of primary care physicians, rising health care costs, and excessive administrative and regulatory costs. This paper, like all ACP policy papers, was developed by a committee of practicing doctors and medical students, reviewed by committees and councils of other members (including medical students, residents, and sub-specialists) and by the elected members of our Board of Governors (state leaders) and Board of Regents. Of course, that doesn’t mean that every member will agree with every one of our positions. Our process assures, though, that our positions are based on the consensus views of the members who have been elected to represent our overall membership and of those who have been appointed to our policy committees.
ACP has also developed a Web tool to enable internists--members compare the positions of the announced 2008 U.S. Presidential candidates against key recommendations from this paper. The purpose in doing so is to get ACP members unbiased, non-partisan information that they can use in learning about each candidate’s positions and how they compare to the policies recommended by ACP. ACP does not endorse candidates or favor one political party over the other.
Q: Why is ACP releasing this paper now?
A: ACP has a long-standing commitment to improving health care in the U.S. Our intention is to provoke a national discussion, during this critical election year, on how to make the U.S. the best-performing health-care system in the world.
Q: What has ACP learned about one system versus the other?
A: ACP’s analysis clearly shows that our country’s current pluralistic system without universal health care coverage is unacceptable and puts us behind other countries.
We found that there is not a single “best way” of achieving universal coverage but we propose two different pathways for consideration: a pluralistic system with universal coverage or a single payer system. ACP does not endorse one option over the other, but instead calls on the public and policymakers to consider the strengths and weaknesses of each approach and decide on which one would work best given the values and unique political culture in the U.S. For instance, on the single payer option, we clearly state that although such systems perform well on most measures of quality, satisfaction, access, and administrative costs, they also are more likely to result in shortages of services subject to price controls and waiting lists for elective procedures. On the other hand, pluralistic models with universal coverage do better on giving individuals the freedom to purchase additional services, but less well on measures of equity (access without regard to ability to pay) and administrative costs.
Q: Is ACP proposing a single-payer system?
A: Not exclusively. Instead we are proposing that all residents in the United States have guaranteed health insurance coverage, and suggest that this can be achieved either through a single payer system or a pluralistic system with guaranteed coverage. ACP’s analysis clearly shows that our country’s current pluralistic health care system without universal health care coverage puts us behind other countries. We hope to accomplish three things. One is to try to persuade the public and policymakers that the status quo is unacceptable. The second is to stimulate a public debate about the strengths and weaknesses of the two considerations we put forward – a pluralistic system with guaranteed coverage or a single-payer system – to achieve a higher performing, more equitable, and more efficient health care system And the third is to make it clear that even if health care coverage was provided to all Americans— either through a single payer system or a pluralistic model with guaranteed coverage—fundamental changes also need to be made in the health care delivery system to improve quality, access, and efficiency of care.
Q: It looks like the issues picked to evaluate the Presidential candidates’s positions (add link) by ACP would favor candidates with a more activist view of the role of the federal government. Why, and how, were these issues chosen, and was it ACP's intent to favor one political party over another?
A: The issues were chosen without regard to any partisan or political preference on the College’s part. ACP’s analysis says unequivocally that the status quo in the U.S. is not acceptable. We put forth two options for consideration that the evidence shows can be effective in assuring that everyone has access to affordable coverage: a single payer system or pluralistic with guaranteed coverage. ACP does not endorse one option over the other, but instead calls on the public and policymakers to consider the strengths and weaknesses of each approach and decide on which one would work best given the values and unique political culture in the U.S.We know that reasonable people—and the Presidential candidates themselves-- will have different opinions on which of these routes to universal coverage is best for the U.S. We know from experience that lessons from other countries can’t simply be replicated here, but our hope is to promote a national discussion, in this critical election year, of how best to achieve universal coverage in a way that best matches the unique history, culture and politic of the U.S., informed by the experiences of other countries with health systems that out-perform the U.S. We hope that both Republican and Democratic candidates would agree with many of the College’s recommendations, even though they may disagree with each other on the best way to achieve a high performing health care system or with some of our specific proposals. Our web-tool can help inform and stimulate a debate about how best to achieve affordable coverage for all, a well-trained physician workforce, informed consumers, higher quality, and lower costs, and a better payment system for doctors—goals that candidates from both parties share.
Q. Given the current level of federal debt and demands on the federal government system, does this country have the resources to create and support a single-payer system?
A: What ACP’s analysis clearly shows is that maintaining the status quo in the U.S. – a pluralistic system without universal coverage – is unacceptable and puts us well behind other industrialized countries. Either of our recommendations for achieving universal coverage—a pluralistic model with guaranteed coverage or a single payer system—will require that tax dollars be collected and organized in a way to make care affordable for everyone. We do not believe that this can be done by private markets alone.
The cost of not providing universal coverage in the U.S. is enormous. It can be measured in dollars, such as the money being spent on emergency room visits by the uninsured, cost-shifting to the insured, lost days from work, and reduced competitiveness for U.S. industries compared to those in countries where health care is paid for by the government. One study recently found that the U.S.—federal, state and local governments, employers, and individual consumers— spends a total of $100 billion per year on the uninsured. Isn’t it much better to take that money and provide coverage for everyone?
But the cost of not achieving universal coverage can also be measured by poorer quality, poorer outcomes, less efficient use of resources, and lower patient and public satisfaction. Our paper provides compelling evidence that the U.S. lags behind every other industrial country on such measures of effectiveness. We also know that high-performing health systems in other countries have explicit workforce and payment policies to provide access to continuous, comprehensive and coordinated medical care by primary care physicians, based on evidence that the availability of primary care is positive associated with better outcomes at lower costs. High-performing health care systems make a greater public investment in basic and health services research, including research on the effectiveness of different types of treatments. They provide patients with access to information to help them make informed choices. They invest in interoperable health information technologies to improve care and have uniform billing systems to simplify administrative transactions.
The U.S. can learn from others and choose to do better.
Q: Where does ACP recommend beginning the process to reform the entire health care system? What are the practical next steps once a system has been selected?
A: The first step is to challenge all of the candidates running for President of the United States to make a commitment to achieving universal coverage and to redesigning other elements of the U.S. health care system, such as workforce and reimbursement policies, to create a high- performing system. The kinds of reforms that ACP advocates will require a commitment from a new President, regardless of party, to proposing legislation to re-make American health care.
It will require a strong mandate from voters. It will require a Congress that agrees on the need for fundamental reform. To this end, ACP has prepared a voter guide for our members to help them evaluate the Presidential candidates’ positions based on the policies being advocated by the College. We believe that both Republicans and Democrats want our country to be second-to-none in the quality, affordability and efficiency of care provided. They may disagree with some of our recommendations, but we will have succeeded if we at least get the candidates to embrace the need for fundamental reforms that include universal coverage, and if we stimulate a debate on how best to achieve this goal.
Q: How does the patient-centered medical home concept fit into either a single-payer or pluralistic system? How would the concept of care change/be adapted for each payment system?
A: The Patient-Centered Medical Home is a way to organize care around the relationship between a primary care physician and their patients, supported by health information technology and better payment systems. Similar models have been used in countries, like Denmark, that have pluralistic systems with universal coverage as well as in single payer systems within the U.S. itself (the VA system) or in countries with single payer systems, like the U.K. and Canada. So, this model can work in either a single-payer system or a pluralistic system with universal coverage.
Q: Which presidential candidate's proposal does ACP support? Which presidential candidate's health care plan is ACP’s proposal most similar to?
A: ACP does not endorse any candidate or any candidate's health platform. We are continually evaluating all of the Presidential candidates' positions and providing information to our members to help them make their own evaluations. ACP’s non-partisan evaluations will be based on how closely the candidates' positions are aligned with several College priority issues, including the recommendations cited in this paper, expanding access leading to universal coverage; recognizing the value and importance of having an adequate primary care physician workforce (including scholarships and debt forgiveness for physicians who elect to practice in primary care specialties, support for primary care training programs, and increased reimbursement for primary care physicians), supporting physician-directed care coordination through a patient-centered medical home; emphasizing the value and importance of prevention; providing financial support and reimbursement incentives for physicians to acquire health information technologies to improve patient care and facilitate care coordination, and reforming the medical liability system.
Q: How have the presidential candidates responded to ACP's recommendations?
A: We are encouraged that several of the candidates have included discussion of these issues in their health care proposals and we encourage all candidates to do the same. Our hope is that the paper, and the tool we developed to go along with it, will help you conduct a personal analysis of the 2008 Presidential candidates and challenge the candidates to address the College’s key priorities. As the ACP Ethics Manual points out, “Physicians have an opportunity and duty to advocate for the needs of individual patients as well as society.” Further, the Physician Charter on Professionalism instructs physicians to “… strive to reduce barriers to equitable health care” through “the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.”
Q: How did you conduct your research and where did you get your data?
A: ACP looked at a growing number of studies that have exposed the poor performance of the U.S. health care system. ACP’s paper cites 104 specific references to support our findings, many of which come from peer-reviewed scientific journals. For instance. a recent survey by the Commonwealth Fund of adults in seven industrialized nations indicates that Americans share ACP’s view that the U.S. health care system is inefficient and could be greatly improved by providing access for all Americans to a primary care physician for continuous, comprehensive, coordinated care.
The Commonwealth Fund survey found that patients in the U.S. are more likely to report experiencing medical errors, go without care because of costs, and say that the health care system needs to be rebuilt completely. As medical care becomes more specialized and complex, adults in all seven countries said they place high value on having a relationship with a regular source of primary health care that is accessible and coordinates their care.
Patients with this model of care – a patient-centered medical home, which ACP proposes – reported significantly more positive experiences, including having more time with their doctors, more involvement in care decisions, and better coordination with specialists and hospitals. They were also much less likely to report medical errors, receiving conflicting information from different doctors or to encounter coordination problems, such as diagnostic tests or medical records not being available at the time of care and duplicate tests.
Q: How does ACP’s plan differ from the AMA proposal?
A: Earlier this year, the AMA, ACP and other medical organizations agreed on joint principles that included a statement that everyone should have access to affordable coverage. Many of the ideas put forth in ACP’s paper are consistent with policies adopted by the AMA. We recognize that the AMA may have some differences of opinion of some of our recommendations, such as whether a single payer system should be considered, and we hope to engage in a collegial discussion with our colleagues in the AMA about where we agree, and where we disagree, and how we can continue to work together to our shared objective of providing all Americans with access to affordable coverage.
Q: How does ACP’s plan differ from the Commonwealth reports that were released over the past few months?
A: The Commonwealth report describes how all of the health insurance reform plans now being proposed by presidential candidates and lawmakers fall into one of three general types-tax incentives and individual insurance markets; mixed private-public group insurance with shared responsibility for financing; and public insurance. The report also outlines key principles for health care reform that all Americans should keep in mind as they consider these plans. Our paper puts forth concrete recommendations for health care reform and universal health care coverage and puts the collective influence of over 125,000 physicians and medical students, the second largest physician membership organization in the U.S., toward influencing the public debate to achieve a high performing health care system. As helpful as the Commonwealth Funds work has been in supporting ACP’s analysis, a non-profit think tank is simply not by itself going to be able to achieve systematic change in the absence of advocacy and support from key stakeholders, like ACP.
The Commonwealth report offered a survey of the health care systems in several other countries. ACP’s paper goes further in terms of performing an analysis on 12 other countries and extrapolating lessons learned from the analysis that ultimately leads to our recommendations for health care reform and universal health care coverage.
Q: How does this paper differ from ACP’s previous access-to-care paper (2002)?
A: ACP’s previous paper, which, by the way, will soon be updated, would have achieved universal coverage through a pluralistic model involving subsidies to buy private coverage and expanded public safety net program. Our new paper goes beyond this by looking at how other countries achieved universal coverage, and proposing two different pathways to achieving it—pluralistic with universal coverage, similar to what we proposed in 2002, or a single payer system. It also differs in that it addresses other changes that need to be made in our health care delivery and financing system. Providing everyone with access to health insurance coverage, although essential, will not create a high performing system if we don’t also adopt policies to assure a sufficient and balanced physician workforce, to reform the physician payment system, and to address other shortcomings of U.S. health care.
Q: How can I register my support and complaints about this paper?
A: To ask other questions, indicate your support, complain about the paper, or to take part in a discussion on the paper go to the discussion area. All comments will receive responses.
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Achieving a High Performance Health Care System with Universal Access: What the USA Can Learn from Other Countries, at www.annals.org. December, 2007
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