Walter Bradley is the Chairman of the Department of Neurology at the school of Medicine at the University of Miami. He has written a long piece (available here) on how he thinks we should solve the uninsurance problem. Here’s the short version:
We all know that the United States health care system is in trouble. The US spends over $2 trillion a year on health care, almost 17% of the GDP. By comparison, Switzerland, Germany and Canada spend about 10% of their GDP on health care, while United Kingdom spends less than 8%. Despite this, the 2005 Commonwealth Fund International Health Policy Survey of sicker adults from six countries, Australia, Canada, Germany, New Zealand, the United Kingdom and the US reported that "(t)he United States often stands out with high medical errors and inefficient care and has the worst performance for access/cost barriers and financial burdens." Moreover, the US lags well behind many other countries in indices of quality of care. In 2005 the US ranked 42nd among the world’s nations in infant mortality, with 6.50 infant deaths per 1,000 live births, behind such nations as Singapore (2.29), Sweden (2.77), France (4.26), Canada (4.75) and United Kingdom (5.16), and was 29th among developed countries in maternal mortality. In 2004, 46 million people (15.7% of the US population, about one-fifth of them children) were without any form of health insurance. Many of these have been without health care for years, though others are between jobs that provide health care coverage. In addition another 50 million people in the US have inadequate health care coverage and would be bankrupted by a serious illness.
Most people without health insurance do not have primary health care and only obtain medical care when they suffer an illness that is sufficiently severe as to take them to the Emergency Department of a public hospital. The stroke or heart attack costs the public hospital and the local taxpayers much more than would the control of blood pressure by a primary care doctor.
Health insurance premiums are skyrocketing. In 2004 the annual premium of an employment-based group plan for a family of four averaged $9,950 and workers are contributing an ever-increasing amount to these premiums. The percentage of people with employment-based health insurance in 2004 was 61 percent and is likely to fall further in the coming years as employers strive to reduce health insurance overheads.
The current system of health care for the medically indigent is fragmented, expensive and inefficient. The exact cost of health care for the uninsured in the US is difficult to assess because it is fragmented between Medicaid, the public hospitals, physicians and the insured public. In fact, the US may well be spending more per capita on health care for those without health insurance through these various sources than it does for those with insurance.
I propose a comprehensive cost-effective system of medical care for those without health insurance, the National Health Service for the Uninsured (NHSU). The creation of the NHSU would not immediately address all the ills of the US health care system, but it would provide health care for those without medical insurance, improve the overall health of US citizens, and introduce cost-saving systems that might eventually help the overall US health care system.
An integrated system of health care for the medically indigent in the United States, the National Health Service for the Uninsured.
This proposal for the provision of improved health care to those without medical insurance envisions no change in the current system of fee-for-service medical care, which would continue to provide for the 80% of the population with private health insurance or Medicare. As now, these patients would continue seeing their own doctors and the health insurance programs would reimburse the doctors, hospitals, laboratories, etc. for the medical services they provide.
The National Health Service for the Uninsured (NHSU) would replace the current fragmented "non-system" for the 16% of the US population that is currently without health insurance. The NHSU would be a comprehensive, cost-effective federal program. It would be an integrated health care system for the uninsured based on a new primary care physician network, and the staff and facilities of public hospitals that contracted to join the program. The NHSU would provide medical services from the family practitioner to the specialist, from ambulatory care and home health services to the hospital and nursing home services. It would provide laboratory services, medications and durable medical equipment, and the services of allied health professionals for all covered patients. When fully operational, the NHSU might approach revenue-neutrality for the US as a whole if it were funded centrally by redirection of monies currently going to provide inefficient and costly indigent care through federal, state and local funding. It has been suggested that the incremental annual cost to the federal government of providing health care for the medically uninsured to the level of that provided by insurance-based and government-based coverage would be $34-69 billion annually. However, the cost to Society of shorter lives and poorer productivity of 50 million people without health insurance has been estimated to be $65-130 billion per annum.
The NHSU would not provide the level of consumer flexibility and
over-utilization that characterizes the US health care system at
present. It would be more like an expanded VA system, providing all the
services needed for comprehensive care of those enrolled in the
program, including primary care. However, it would do so in a
cost-contained format. Increased efficiency and cost-containment
programs would be likely to reduce the per capita costs of the NHSU
well below that of insurance- and Medicare- based health care. When
fully operational the NHSU would likely reduce rather than increase the
total cost of US health care.
Financing the NHSU could either be via the creation of a new federal
fund or alternatively it could be based on an expansion of the current
federal Medicaid fund. The monies currently going to provide health
care for the medically uninsured from federal, state and local programs
and from hidden cost-shifting to health insurance companies could be
centralized through a system of tithes on current providers.
Alternatively a new federal tax could be instituted to support the
NHSU, with consequent savings to those health care entities and
providers currently funding indigent care. Viewed from the perspective
of the US health economy as a whole the changes would probably be
Efficiency and cost-containment in the NHSU
Physicians would have
to play a large role in the administration of the NHSU. However, these
physicians would be salaried and not be placed in the currently
ethically challenging position of being paid more for providing more
services. The NHSU would not involve fee-for-service reimbursement. In
this regard, the NHSU would be like the British National Health
Service, where physicians are salaried, and where
physician-administrators are involved at all levels, based on the
concept that physicians are best able to make priority judgments about
allocation of scarce resources.
The current US health care system is characterized by layers of
bureaucracy that relate to the efforts of Medicare and insurance payers
to minimize costs and to the efforts of providers to maximize
reimbursements. Administration and bureaucracy absorbed over 30% of
total health care expenditure, over $300 million or more than $1,000
per capita in the United States, compared to about $300 per capita or
16% in Canada. The in-house cost of administration of the NHSU would be
of the order of 5%, which is comparable to that of Medicare and
Medicaid, much lower than the 12% of commercial insurance companies.
Greater participation of physicians in the administration of the
NHSU, removal of the profit motive and the necessity of working within
fixed annual budgets would allow medically appropriate decisions to
control utilization. It would stimulate the development of
cost-containment programs based on the use of medical guidelines and
practice parameters to reduce over-utilization, implemented by
physician education programs. Physicians and public hospitals providing
services for the federal NHSU program could be granted sovereign
immunity. The introduction of compulsory arbitration programs and a
national insurance scheme for patients suffering medical injury,
similar to the Neurological Injury Compensation Act of the State of
Florida, the United States National Vaccine Injury Compensation
Program, and the New Zealand no-fault compensation program for medical
injury could dramatically reduce the costs of malpractice insurance and
defensive medicine. Bulk purchases of medications, goods and services
by the single- payer NHSU could result in a savings in excess of 20% on
The primary care physician (PCP) base of the NHSU.
At present, those who have no health insurance in the US receive no
primary care services and hence the NHSU would need a large number of
PCPs. The US currently has about 400 PCPs/million population, compared
to the United Kingdom with about 700 and Canada about 1,000
PCPs/million. Based on these figures, the NHSU would need at least 500
PCPs/ million of enrolled individuals, or about 25,000 new PCPs. This
number is daunting, since it is 1.6 times the total number of medical
students graduating each year from US medical schools, of whom only
one-third enter the primary care disciplines of family practice,
general internal medicine and general pediatrics.
There are several ways in which this need for additional PCPs could
be met. The number of medical students graduating each year from US
medical schools has remained static for a decade or more and many
health care professionals, including the American Association of
Medical Colleges have been calling for an expansion of medical school
places. A higher proportion of graduating medical students could be
attracted to become PCPs by the opening of a well-paid and salaried
primary care track in the NHSU. Newly graduated doctors could be
further attracted by a program to forgive student loans in return for
two or three years of primary care service in the NHSU, similar to that
currently offered through the National Health Service Corps. Finally,
the new primary care network of the NHSU would attract well-qualified
foreign medical graduates. The specialist physician base of the NHSU.
The specialists of the NHSU would predominantly come from the current
staff of the public hospitals already providing care to the medically
indigent population. Many of these are the clinical faculty of US
medical schools. These physicians, whether attached to a public
hospital or a medical school, could be either full-time salaried
employees of the NHSU, or alternatively they could have part-time
appointments split between fee-for-service practice and the NHSU in the
same way as academic physicians can
The hospital base of the NHSU.
Currently in the US, hospital services for uninsured patients are
provided by public hospitals, many of which are affiliated with medical
schools. Hospitals would contact with the NHSU to provide services for
patients that would not be based on fee-for-service reimbursement. The
NHSU would be based on a network of community based primary care
centers evenly distributed throughout the country on a per capita
basis, linked to small regional hospitals and geographically
distributed large specialty tertiary care hospitals. This would be
similar to the Veterans Health Administration system where regional VA
Medical Centers provide hospital services for patients whose ambulatory
care is provided by decentralized VA primary care sites.
The hospitals contracting with the NHSU would be funded to provide
care for the NHSU patients based on a capitation fee related to the
total number of subjects enrolled in the NHSU in a given drainage area.
The "threat" of migration of beneficiaries from employment-based
health insurance to the National Health Service for the Uninsured.
The NHSU would be available to every US citizen who lacks health
care coverage through Medicare and employment-based commercial
insurance. Ultimately, it is likely that Medicaid would also be merged
into the NHSU.
An argument that has been raised against the NHSU is that employers
would stop providing health insurance for their employees, thereby
forcing them to join the NHSU program. This argument fails to recognize
that the NHSU would be a very different system from the current US
fee-for-service system, even with all the restrictions imposed by
Medicare and the health maintenance organizations. NHSU patients would
not have open access to specialist physicians, other than through their
PCP. Prescription medications would be provided on the basis of
cost-effectiveness using generics wherever possible, and an information
base similar to Consumer Reports Best Buy Drugs program.
Investigations, like MRI scans and expensive laboratory tests would not
be freely available and their use would be based on practice parameters
and evidence-based medicine. The NHSU would have more in common with
the US Veterans Health Administration system or the provincial health
care systems in Canada34-36 than with the current US fee-for-service
system. The NHSU would provide cost-effective medical care for all who
need it and a safety net for the 50 million citizens who otherwise have
no health care. However, it would be less attractive for employees than
insurance-based health care. Unions and prospective employees would
still seek to have health insurance provided by employers as a fringe
benefit. Medicare recipients and lobbying groups like AARP would fight
hard to keep the fee-for-service or HMO models of health care rather
than that provided by the NHSU.
This proposal for a National Health Service for the Uninsured would
not interfere with the health care of the majority of the US public.
Limited to the 15% of the population without health coverage, the NHSU
should be politically acceptable to most of the US voting public, who
currently have government- or employment-based health insurance. The
NHSU would provide a comprehensive integrated national health care
system for the medically indigent that extends from a new primary care
service to a system of tertiary referral hospitals and specialists. The
US public could feel proud of the NHSU, rather than embarrassed at
having nearly 50 million Americans without basic health care. The NHSU
would probably result in a net savings to the US when compared to the
current costly fragmented "non-system" of emergency medical services
for the medically indigent and the cost to Society of ill health and
shortened lives. The NHSU would aid in the development of a primary
care infrastructure that the US has long needed. The NHSU might
ultimately be instrumental in bringing under control the double-digit
rate of inflation of medical expenditure in the US by providing
templates for cost-containment for the insurance- and Medicare-based
health care system. The NHSU would raise the overall standard of
medical care in the US and hence improve the international standing of
the US in measures of health care quality and outcomes.