ACP, AMA and Health Care Reform…15 Years Later

Posted on | December 8, 2007 | Comments Off on ACP, AMA and Health Care Reform…15 Years Later

Will organized medicine lead or spoil?

By Mike Magee

From 1990 to 1997, I was in Philadelphia at Pennsylvania Hospital and Jefferson Medical College. This gave me a front row seat of what I called the Medical School Wars – the highly publicized battle for market share between the University of Pennsylvania, Jefferson Medical College, Temple, Hahnemann (Allegeny), and Cooper. At the same time, a less public skirmish was going on in Philadelphia within one of Medicine’s most widely respected national organizations – The American College of Physicians, otherwise known as the ACP, representing today some 124,000 Internal Medicine physicians in the United States. That intramural civil war within the “House of Medicine” centered around health care reform. Most of the national associations supported the status quo, but the ACP decided to support Healthcare Transformation. Here’s how Time magazine and CNN reported the opening salvo on May 7, 1990:

“… it came as a shock last week when the American College of Physicians, the U.S.’s second largest medical society, called for comprehensive health-care reform that would include some form of national financing. The announcement, made in Chicago at the A.C.P.’s annual meeting, marks the first time that a doctors’ group has backed an overhaul of American medical care. And it puts the 68,000-member group at direct odds with the powerful 300,000-member American Medical Association, which has been opposing sweeping change for at least 30 years. Says Dr. John Ball, the A.C.P.’s executive vice president: “We hope to produce some leadership for the medical community.’ ”

The Clinton Health Care proposal, The Health Security Plan, surfaced in 1993, and was fully covered in the ACP’s Archives of Medicine. Here’s how ACP member and former Robert Wood Johnson President, Steve Schroeder summed it up in an article in 1993:

“These cautions aside, the unveiling of the Health Security Plan appears to be the best chance yet for Americans finally to achieve universal health care coverage. The Health Security Plan, with its huge scope and complex structure, is the most important U.S. health policy development since the enactment of Medicare and Medicaid. Perhaps the worst outcome of the forthcoming political debate would be to sacrifice the commitment to universal coverage because of the understandable concerns about costs, the deficit, and the economic vulnerability of small businesses. The natural political instinct to phase in expanded coverage should be vigorously opposed by physicians and the public. Only by having everyone in the system can we be sure that it will best serve the public. In whatever ways the Plan may evolve in the next year, let us hope that Congress and the President will stand firm on the principle of providing basic health care for everyone. This is an achievable dream, which the art of politics must now render.”

The year that followed was filled with charges, counter charges, manuvering in Washington, orchestrated TV campaigns, and finally the collapse of the movement. One of the fall-outs was a change in the leadership at the ACP in 1994. So it is fair to say that this organization, when approached with the concept of fundamental Health Care Reform is a veteran in the field and fully aware of the benefits and risks that come with being out front on this issue. And that is why this week’s release of the ACP Policy Paper on Health Care Reform is so significant and suggests we are once again at a turning point. In the ACP’s words:

“We know that ACP’s 124,000 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.”

The big question: What will be the House of Medicine’s role this time around: leader or spoiler?