Incrementalism versus single-payer health care reform
Different routes to the same solution.

Cross-posted to Clinical Correlations (with some edits there)

Health insurance positions: The obvious imperfections of our current health care system have inspired a number of solutions. They can be organized into two broad categories, incremental or single-payer. Each of these solutions is advocated by a single-issue lobbying group. National medical organizations support these solutions in greater or lesser measure.

Advocacy groups: Physicians for a National Health Program provides information about the benefits and practical implications of a single-payer health care system. The list of members of its advisory board includes their organizational affiliations, but (as its name indicates) the group is composed of physicians, not medical organizations or professional societies.

Incrementalism is represented by the National Coalition for Covering the Uninsured, a broad-based coalition of a number of organizations, including the AMA, the American Hospital Association, the American Public Health Association, the American Academy of Family Physicians, pharmaceutical companies, insurance companies and other organizations. Given the divergent range of interests and philosophies represented by this list, it's no surprise that the NCCU's plan involves a number of less wide-reaching improvements in the current system, including transparent pricing; personal Medical Savings Accounts; and the expansion of public programs to cover the very poor.

Professional organizations: Many medical organizations act as both professional societies and as advocacy (i.e. lobbying) groups. Their "home" positions may in many cases differ from their compromise positions hammered out in coalitions with others. The American College of Physicians, on its Web site, advertises its support for the Health CARE Act, a proposal which would increase federal matching funds to those states expanding Medicaid coverage to all those beneath the federal poverty level, and which would also provide increase federal funding to those states which increase coverage for uninsured children.

For its part, the American Medical Association "will strongly advocate for incremental measures to expand coverage," and in keeping with this advocacy is a member of the HCCU. In the long term, says its Web site, it will continue to push for the adoption of a market-based plan to expand coverage, "relying upon incentives and voluntary approaches." Similarly, the American College of Surgeons endorses universal access to care "within our current pluralistic health care system," i.e. to be incremental in the pursuit of change, with some features being implemented on a state by state basis. The ACS further emphasizes that "reducing health care costs [through improving information technology] is much more desirable than containing costs by rationing care."

Compared to other professional organizations, the American Academy of Family Physicians is full-throated in its advocacy of a plan to ensure health care coverage for all. On its web site, it lists those services which should be covered for all who reside in the United States (a relevant distinction in these days of proposed immigration reform). Assured services with no co-payment include prenatal/maternity care; well baby/child care; evidence-based childhood and adult immunizations; and evidence-based periodic evaluation and screening services. Other assured services, including outpatient physician services and outpatient prescription medications, would require 20% co-payment. The AAFP is also the rare organization which specifies a funding mechanism: a national, broad-based tax. Under the AAFP plan, coverage would be rationed by a "resource-based relative value system."

Differences and similarities: The differences in advocacy positions - taken on their own and as participants in coalitions - of the American professional medical organizations remind practicing physicians, and especially physicians in training, that the current health-care system can justify various solutions. Advocacy can also be modified in coalition for the sake of practical lobbying.

Personally, I think a single-payer system is the only solution that would fix the gaping inequities in our system -- but I also realize that there are many ways of getting there. PNHP might better fit idealists, and NCCU, realists, but they have a goal in common: reducing the numbers of the uninsured. Perhaps the coalitions can themselves coalition to put the problem of the uninsured higher on the agenda of the 2008 elections.

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