TY - JOUR
AU - Schoenbaum, Stephen C.
AB - Abstract We enter this century with an unprecedented federal budget surplus–$4.6 trillion over the next 10 years.1 A substantial portion of the surplus comes from savings in the health care sector. The 1997 Balanced Budget Act cut payments to Medicare providers and raised the premiums for individual beneficiaries, but we overshot the mark. Instead of balancing the budget, we generated a huge surplus. We underestimated the magnitude of Medicare savings. Medicare savings over the period from 1998 to 2007 represent an estimated 15% of the total budget surplus.1,2 Fifteen percent of the 10-year budget surplus from 2001 to 2010 comes to $680 billion. We also underestimated the drop-off in Medicaid coverage, as welfare reform took hold. In the year 2000 Medicare and Medicaid outlays were an estimated $104 billion less than projected just 5 years ago–representing an estimated 45% of the budget surplus this year, or about $1 trillion of the 10-year surplus.1,3 We also underestimated the strength of our economy. But let's not underestimate what we can achieve with our new prosperity. Let's not shrink from the responsibility of pointing out what needs to be done. It is time to give some of the surplus back to health care. Nor is the task really as daunting as some make it seem. Employer health plans, Medicare, Medicaid, and other forms of insurance already cover 84% of our citizens.4 It is the most vulnerable who are left behind. A goal of expanding employer plans, which now cover 155 million people, and Medicare and Medicaid, which together cover 70 million people,5-7 by just under 20% would provide coverage for all of America's uninsured. We need a bold approach, one that does justice both to the magnitude of the problems in the current system and to our economic resources, technological capacity, creativity, and commitment of health care professionals and leaders. Such a system may not be achievable in the next 4 years, but it should be achievable within a generation. It is called "A 2020 Vision for American Health Care." It has 5 basic features: (1) automatic and affordable health insurance coverage for all; (2) access to health care for all; (3) patient-responsive health care; (4) information-driven health care; and (5) commitment to quality improvement. Automatic and affordable health insurance coverage for all Automatic coverage for all, with everyone contributing fairly to settling the bill when it comes due–employers, taxpayers, patients, health care providers, and insurers—is the first feature. The results of a recent study on pension plans were startling. When employers provided matching funds for employee pensions and left it up to employees to decide to participate, only about 40% signed up. When employers enrolled employees in an investment plan and deducted the employee share from their paycheck unless they opted out, nearly 90% participated.8 The financial benefits and costs are the same under either mechanism, so rational consumer decisions should not change. But they do. Automatic enrollment makes a big difference. We have 10 million uninsured children in this country—including 8 million who are eligible for Medicaid or the new CHIP (Child Health Insurance Plan) program.9 Focus groups reveal that it is not lack of desire to have their children covered that keeps families from participating.10 They just do not know about the programs, do not believe they are eligible, or find the enrollment process too daunting or humiliating. Automatic enrollment and making it easy to get and keep insurance is an important feature of any plan seeking to expand coverage. That does not mean that people should not have choices and information on which to base those decisions. It means that there needs to be a good default system in place that operates automatically until a conscious, informed choice is made. The first question is this: what are the best vehicles for providing coverage? We should be guided by what people prefer, not by what we, as analysts or policy advocates, believe is best. A recent Commonwealth Fund survey of American workers found that, by and large, people prefer employer-based health coverage.11 There are some differences among groups. Not surprisingly, most of those who are already covered by an employer prefer that option, but even lower-wage workers who do not have employer coverage seem to want what other American workers have: good health coverage on the job. So, let's start with employer-based coverage. "2020" envisions a system wherein any employer who offers health benefits to at least some workers, would see all workers—including part-time, temporary, and new employees—automatically enrolled in that employer's plan unless an employee opted out. Many workers find themselves uninsured temporarily, between jobs—today only 20% of departing employees take up COBRA coverage, and cost is not the only deterrent. Under this plan, all workers and their dependents would automatically be covered by a former employer for up to 18 months unless they opted out. We estimate that these 2 provisions could extend coverage to more than 6 million uninsured workers and their dependents. Employer plans typically cover dependent children up to the age of 18 years, or in the case of full-time college students, up to the age of 23 years. This is a custom that makes little sense in today's world. The results of a recent Commonwealth Fund study showed that uninsured rates are highest among young adults aged between 19 and 29 years. The current practice of covering dependent children only if they are full-time college students is an extra burden on working families whose children cannot afford to go to college or who attend part-time while working in a job without health benefits. Automatically covering all young adults up to age 23 years under their parents' policies would provide coverage to an estimated 350,000 young adults who are still dependent on their parents yet are no longer on the family policy. But not all employers offer coverage, especially small firms that cannot afford rising premiums. A default option for workers at these firms would be to let employers that do not provide coverage participate in the Federal Employees Health Benefits Plan (FEHBP), which insures 9 million federal employees and their dependents. Opened to all the working uninsured, this option could be available to more than 30 million. Even if only half of those eligible were enrolled through this option, it would reduce the number of nonpoor uninsured by as many as 13 million people. Opening up this program initially nationwide to uninsured self-employed people and employees of small businesses would offer group coverage rates to 16 million uninsured working adults and their dependents. An estimated 5 million could be expected to participate. Building from this new base, and then finding a way to bring employers and employees in, and making coverage automatic is the challenge to public policy. The goal would be to make the benefits of group coverage and easy enrollment available to all who work for a living. But expanding options through employment is only one step. Those looking forward to retirement or too sick or disabled to work full-time also need an easy route to coverage. So, the second step would be to build on Medicare. A recent Commonwealth Fund survey found that adults aged 50 to 70 years tend to trust Medicare as a source of coverage more than other sources–including employer coverage.12 Two thirds said they would buy into Medicare early if they had the option. A 2020 Vision for American Health Care would automatically extend Medicare coverage to any uninsured person meeting the following criteria: (1) anyone who is disabled but not yet eligible because of the current 2-year waiting period; (2) any adult aged 55 years and older; (3) any dependent of a Medicare beneficiary; (4) anyone denied private insurance for health reasons; (5) anyone diagnosed as having a serious health problem (eg, cancer) or hospitalized for a serious illness; and (6) anyone whose expenses in a given year or the past 5 years exceeded $30,000. The willingness of Medicare to take anyone regardless of health status, prior health condition, or major health expenditures could be expected to markedly lower the cost of private health insurance to employers and working families. An analysis of the distribution of claims expenses, for example, finds that if the sickest 1% are excluded from the nongroup private insurance market, the average cost of coverage drops by more than 20%. To a large extent, Medicare and Medicaid already serve as insurers of last resort by covering elderly persons and disabled persons who meet either the work history requirements of Medicare or the income and asset requirements of Medicaid. Making Medicare the default option for coverage for those barred from private coverage would extend the definition of the disabled to include people with the sorts of serious health problems that make them unattractive to private insurers. Finally, Medicaid and CHIP would be expanded to cover automatically all families and single individuals with incomes below 100% of poverty not otherwise covered by employer plans or Medicare. Adults and children covered under public programs such as food stamps; the Women's, Infants, and Children Nutrition Program; and school lunch could be automatically enrolled to avoid the need to apply twice. Recent legislative restrictions on coverage of legal immigrants under Medicaid could be repealed. Anyone covered by Medicaid or CHIP could have the option of remaining covered under this plan for up to 18 months after otherwise losing eligibility by virtue of a new job, a higher wage, or otherwise improved economic condition. In combination, these Medicare and Medicaid expansions would provide public options for an estimated 26 million or more currently uninsured low-income or sick or older adults and their dependents. Those aged 55 years or older or sicker individuals with low incomes would be newly eligible for both Medicare and Medicaid. Eight million uninsured children are eligible for Medicaid or CHIP. An additional 18 million would be newly eligible from legislative expansions of Medicare and Medicaid. Coverage of a total of 26 million would depend on effective enrollment mechanisms to reach all eligible low-income people. While these default options guarantee new coverage and the hope of more automatic coverage for virtually every American, actual enrollment would be guided by families' preferences for coverage (Figure 1). If a family eligible for employer coverage preferred Medicaid or CHIP, that option would be available. If a working adult eligible for Medicare preferred employer coverage, that option would be available. In addition, FEHBP, Medicare, Medicaid, and some employer plans offer choices among managed care plans as well as traditional indemnity coverage. Choice of plan would be guided by individual and family preferences, based on information including the cost and quality of care under alternative choices. Outreach and educational campaigns would seek to maximize the number of those exercising their own preferences for coverage. For those not making a choice, individuals would be assigned to a plan that assures, to the extent possible, continuity in the source of health care. Coverage would be assured even in the absence of active choice. Who should pay, how much? Now, to the hard part—who should pay how much for coverage? Previous attempts to achieve universal health insurance under former Presidents Richard M. Nixon and Jimmy Carter and Bill Clinton's attempt failed in part because of this issue. The one new element today is a significant federal budget surplus. There are many competing claims for this $4.6 trillion 10-year pie—tax cuts, funds to make Social Security Insurance solvent for 75 years, increases in federal funding for education, the environment, and other domestic and national security purposes. But remembering that this surplus came about in part because of belt-tightening by the health care sector and a marked slowdown in Medicare and Medicaid outlays, health care can certainly lay claim to a major share. What is more, Americans want to see the problem of the uninsured solved and those currently insured hope for more secure future coverage for themselves. Opinion polls show that covering the uninsured and improving Medicare benefits rank high in public preference, well above tax cuts. But a federal budget surplus is not the whole solution. Rather, it provides some breathing room, an opportunity to remake the system. For even if the surplus were dedicated entirely to health care, it could not finance a sector that costs more than $1 trillion annually. The parties that currently finance the health care system—employers, workers, retirees, patients, taxpayers, and health care providers, including the institutions that subsidize care through bad debt and care for the indigent—all of us must continue to share the burden. With a budget surplus we can make those contributions fairer and more affordable for all. The work immediately ahead is to reach a national consensus on how much should be forthcoming from each source. A 2020 Vision for American Health Care could start by suggesting that employers continue to contribute at current levels, but in any case not more than a fixed percentage of payroll. Employers paying more than that percentage could be eligible for tax credits or subsidies to offset their higher costs. Or they could apply the excess against current employer payroll or business taxes. Employers offering coverage for the first time could be eligible for phased-in contributions of, say, no more than 1% to 2% of the payroll in the first year, gradually increasing to a maximum contribution. Employers not wishing to participate could still opt out, but could face certain penalties, such as ineligibility for federal government contracts or business subsidies or paying into a public pool for coverage. Individual and family contributions for medical expenses and health insurance premiums could be capped as a percentage of family income. Individuals not wishing to participate could opt out, but would face uninsured medical expenses in the event of illness. For insured families, expenses in excess of the cap could be offset through refundable tax credits or tax subsidies, or applied against withholding for taxes such as payroll or income taxes. Families with incomes below the federal poverty level could be forgiven any premiums and cost-sharing for covered services. State governments could continue to meet their present obligations, not to exceed the current average per capita state and local government contribution for health care. Health care providers could continue to dedicate a portion of revenues for uninsured services—either emergency care to undocumented immigrants or noncovered services such as outreach and patient education. Health insurers and managed care plans could continue to pay current taxes and assessments for bad debt and charity care. So all parties could be expected to contribute to solving this national problem. Estimating the exact cost of this plan will require greater specification of benefits, administrative mechanisms, and expected choices by families and employers. In any event, it is unlikely to be cheap, even retaining existing sources of financing. An educated guess would put the price tag at around one fourth of the estimated federal budget surplus over the next 10 years. Of course, none of the sources of financing is sacrosanct. An extended national debate regarding what are fair and affordable contributions from each party would be a healthy dialogue. Testing the willingness of all sectors to work together and to share in the cost of affordable health insurance coverage is an important starting point. But the plan retains a number of values held dear by most Americans: choice (including the choice of not participating), choice of plan, and choice of health care as well as major role for private coverage rather than a one-size-fits-all approach. Such an ambitious plan also requires new administrative mechanisms, which will take time to create. Some elements of the plan lend themselves to earlier action than others. Design and implementation of automatic enrollment will require extensive work to identify current sources of coverage and care and to minimize disruption. Efficient enrollment processes will undoubtedly rely on Internet tools to permit individuals and employers to obtain information on plan choices and indicate preferences, or change source of coverage. A new e-HEALTH or e-FEHBP mechanism may be required to facilitate choice, enrollment, and subsidies for coverage. Outreach to those without Internet access—efforts such as enrollment at sites of health care, through toll-free numbers, at federal and state government offices, and through community organizations and consumer advocacy groups—is an option. Access to health care for all The absence of health insurance coverage is the single most important reason why Americans fail to receive necessary health care. It is the fundamental flaw in our health care system. It puts tremendous financial stress on institutions—such as academic health centers—struggling to provide care to the needy and to those with the serious conditions that require specialized services. It is at the root of the complexity of our system, causes fear and delay on the part of patients, and makes it impossible for physicians and other professionals to provide the kind of care they desire and are trained to provide. The system works best when everybody can pay for care. It is impossible to ensure for everyone the kind of health care that we want for ourselves and our families without acting as a nation to achieve this goal—health insurance for all. Genuine access to health care requires more than just an insurance card. Two conditions are particularly important: comprehensive benefits and a personal physician or other clinician responsible for the care of every person. Benefits must be sufficiently comprehensive to give patients access to the full range of services required to assure good health and treat illness. These include preventive care, prescription drugs, mental health care, and preventive and emergency dental care. Excessive deductibles and copayments can deter entry into the system and render coverage a hollow promise. The Commonwealth Fund studies of lower-income insured families find widespread evidence of failure to obtain needed care and difficulty paying medical bills because of inadequate insurance coverage, because of either limits on covered services or high out-of-pocket costs.13 Underinsurance is not a sufficient remedy for uninsurance. Access also requires that there be an easy entrée into the system for every American. In an ideal world, every person would select a personal physician or clinician to serve as his or her advocate, helping to ensure regular preventive care and appropriate treatment for acute, chronic, and emergency conditions. Some patients may prefer to have an advanced practice nurse or a nurse-midwife as their primary source of care. Patients with complex problems may be more comfortable with a specialist. Patients could change their designated personal clinician over the course of an illness. But at every point in time it must be clear to the patients and their caregivers that one person is coordinating the care and is trained and capable of doing so. To encourage patients to select a personal physician or other clinician, an annual visit would be covered without charge to discuss any issue of concern to the patient. Patients would have easy access to relevant information. This would include information on how to choose a physician and make an appointment. It would also include data about the physician's credentials, office locations and hours of practice, as well as information about age, gender, and race. Information on quality of care, including reports by patients in the physician practice on their experiences, and clinical measures of quality of care, including peer assessment of practices, would also be made available. Patient-responsive health care Coverage, comprehensive benefits, and a regular physician or advanced practice nurse would go a long way to making health care more responsive to patients. But a patient-responsive health system ideally would make care accessible to patients when patients need and want that care. To assure timely access, physicians and other heath care providers should set and make known hours of operation, and adhere to standards on timely appointments and waits once the patient has arrived at the place of care. Physicians and other health care providers should also set standards for timely response to telephone calls or e-mail inquiries. Practices should be encouraged to adopt open access models of scheduling, including letting patients schedule their own appointments by telephone or over the Internet. American health care will inevitably remain complex and confusing to patients. A serious illness often requires the services of dozens of different health care professionals. Errors can be made when patients are handed off from one health care provider to another and from one site of care to another. Communication often breaks down, forcing patients to repeat the same information over and over, leading to delays while medical records are retrieved, or causing needless and costly repetition of tests. Assuring that care across multiple health care providers and sites is coordinated by the patient's designated clinician would go a long way to address these issues. Taking responsibility for coordinating care also means a system for keeping track of preventive services, reminding patients of appointments and following up to make certain care is obtained, and providing periodic counseling on adopting and maintaining healthy behaviors such as diet, exercise, smoking cessation, and adherence to treatment protocols. When appropriate, referrals to organizations or professionals skilled at counseling are also part of patient-responsive care. Nutritionists, exercise physiologists, and behavioral health specialists are all important members of a health care team, whose skills can be effectively tapped to ensure that patients receive the kind of expertise that will have long-term benefits for improved health, functioning, and quality of life. Information-driven health care Unlike other parts of the American economy, the health care system has not yet embraced modern information technology, which is viewed as too expensive, unrewarded—too divergent from current practice to make such fundamental changes as introducing electronic medical records or computerized physician order entry systems. A recent Commonwealth Fund survey of 5 countries found that these systems are already widespread in general practice in the United Kingdom and New Zealand.14 If countries that devote a fraction of what the United States spends on health care can move in this direction, we can as well. One key is promulgation of federal standards. It took federal standards to agree on the content of the uniform hospital discharge abstract. It will take federal standards to agree on what the minimum content of health information systems should be. The goal is easy exchange of information among health care providers and to patients themselves. We need to ensure that patients have easy access to their complete medical records. Increasingly patients want information; information itself can be seen as a form of care. Patients have a right to know about the treatment they are receiving and about the quality of care provided by those who are caring for them. They want information on their diagnosis and options for treatment. They want patient-education guides to know what they can do to help ensure their full recovery and achieve the best outcomes. They want patient-education guides on prevention and maintenance of chronic conditions. Parents want information from their pediatric practices on what they can do to help their children grow and develop. Informed patients are better patients. They are an untapped resource and ally in preventing error and improving patient safety. Information systems are also key to helping those on the front lines of care. Good information systems would assure good transmission of information between personal physicians and specialist referrals and between personal physicians and other sites of care, including hospitals. Good information systems help physicians have quick access to laboratory tests and medical records. Good information systems also have significant potential to prevent medical errors, aid in diagnosis and treatment, and provide benchmark information on standards of practice and patient outcomes among one's peers. Commitment to quality improvement The health care sector is fortunate to attract health care professionals and other health care workers truly committed to caring and curing. Health care professionals and leaders need to advocate not only for provision of the best care that modern medical science has to offer, but also for the development of a system that measures quality by the degree to which the provision of care is truly patient-responsive. Professionalism is at the heart of excellence in medicine—professional ethics that include making a lifetime commitment to doing what is best for the patient. A 2020 Vision for American Health Care would keep professionalism at the core of American medicine. In stressing the business aspects of health care, we have been in danger of losing that which we all value most highly as patients—a commitment to the highest-quality care. Somehow we have let a concern with cost get in the way of doing what is best for patients and have let financial pressures dictate what care is provided—or not provided. A 2020 Vision for American Health Care should also embrace a commitment to quality improvement by every one of the 9 million people working in this sector. Physicians, other health care professionals, hospitals, and other health institutions need to make quality the number one priority. A genuine commitment to quality improvement, including periodic board recertification and peer assessment for physicians and other clinicians, public release of quality information, and participation in quality improvement and patient-safety initiatives must become commonplace in American health care. Professionalism values accreditation not only of institutions but also of practicing clinicians. Health care institutions and physician office practices would be expected to devote resources to clinical information systems to aid decision making, measure quality of care, and promote quality management. In return, payment for medical services would include a specific portion to cover such expenditures. Insurers and government payers would perform periodic audits to ascertain that the information systems and quality management processes were operational. Education of health care professionals would include specific training in quality management and patient-responsive care. The nation's academic health centers and health professions schools would be encouraged to reexamine curricula to ensure expertise in information systems, quality measurement and improvement, patient safety, coordination of care, patient communication, cultural competency, and experience working in health care teams. Hospitals, physicians, and other health care professionals and organizations would be encouraged to participate in networks committed to comparing quality outcome results on an ongoing basis, identifying best practices, and adopting improved processes of health care. All health care professionals and organizations would be encouraged to adopt nationally approved clinical guidelines relevant to their practice and to institute processes for ensuring adherence to guidelines. Financial incentives could help motivate health care organizations and physicians to achieve higher quality results. While professionalism and professional recognition are key to quality improvement, financial rewards can also serve to reinforce quality improvement efforts and provide another type of recognition. Conclusions We should strive for a health care system that guarantees access to high-quality health care to every American—a system in which everyone can afford comprehensive health insurance; a system that mobilizes the latest information technology to improve coordination of care and help patients become partners in their treatment. Health leaders should be advocates and role models—not only for technological innovation and care for the poor, but also for the development of a system in which quality is the shared goal that we all work together to ensure. We have the economic and intellectual resources to create such a system, and in doing so we will earn for ourselves a more decent society, a healthier people, and an even stronger economy. Once and for all, we will secure for our families and ourselves the best that modern health care has to offer. Accepted for publication October 9, 2000. Adapted from the John R. Hogness Award Lecture given at the annual meeting of the Association of Academic Health Centers,Tucson, Ariz, October 5, 2000, and available online at The Commonwealth Fund Web site (http://www.cmwf.org.. We thank Sherry Glied, PhD, associate professor of Public Health and Economics, Division of Health Policy and Management, Columbia University, New York, NY, Joseph L. Mailman School of Public Health, for coverage estimates based on analysis of the March 1999 Current Population Survey. We also thank Erin Strumpf, special assistant to the president and research analyst at The Commonwealth Fund, New York, NY, for assistance with research and preparation of the final manuscript. The views expressed herein are those of the authors and should not be attributed to The Commonwealth Fund or its directors, officers, or staff. Corresponding author: Karen Davis, PhD, The Commonwealth Fund, 1 E 75th St, New York, NY 10021-2692 (e-mail: kd@cmwf.org). Reprints: The Commonwealth Fund, c/o Best Assembly Inc, 373 South St, Eatontown, NJ 07724. References 1. Congressional Budget Office, The Budget and Economic Outlook: An Update, July 2000. Washington, DC Congressional Budget Office2000; 2. Congressional Budget Office, Budgetary Implications of the Balanced Budget Act of 1997. Washington, DC Congressional Budget Office December1997; 3. Congressional Budget Office, Economic and Budget Outlays: FY 1996-2000. Washington, DC Congressional Budget Office January1995; 4. US Census Bureau, Health Insurance Coverage Based on March 1999 Current Population Survery. Washington, DC US Census Bureau September2000; 5. Fronstin P Sources of Health Insurance and Characterists of the Uninsured: Analysis of the March 1999 Current Population Survey. Washington, DC Employee Benefit Research Institute January2000; 6. Kaiser Commission on Medicaid and the Uninsured, Medicaid: A Primer. Menlo Park, Calif Henry J. Kaiser Family Foundation August1999; 7. Health Care Financing Administration, Medicare Enrollment Trends, 1966-1998. Washington, DC Health Care Financing Administration June30 1999; 8. Madrian BCShea DF The Power of Suggestion: Inertia in 401(K) Participation and Savings Behavior. Cambridge, Mass National Bureau of Economic Research May2000;Working Paper 7682. 9. Thorpe KEFlorence CS Covering Uninsured Children and Their Parents: Estimated Costs and Number of Newly Insured. New York, NY Commonwealth Fund July1998; 10. Feld PMatlock CSandman DR Insuring the Children of New York City's Low-Income Families: Focus Group Findings on Barriers to Enrollment in Medicaid and Child Health Plus. New York, NY Commonwealth Fund December1998; 11. Duchon LSchoen CSimatov EDavis KAn C Listening to Workers: Challenges for Employer-Sponsored Coverage in the 21st Century. New York, NY Commonwealth Fund January2000; 12. Schoen CSimantov EDuchon LDavis K Counting on Medicare: Perspectives and Concerns of Americans Ages 50-70. New York, NY Commonwealth Fund July2000; 13. Donelan KDesRoches CMSchoen C Inadequate health insurance: costs and consequences. Medscape Gen Med [serial online]. 2000;2 ((No. 41)) Accessed August 11, 2000.Google Scholar 14. Schoen CDavis KOsborn RBlendon R Commonwealth Fund 2000 International Health Policy Survey of Physicians' Perspectives on Quality. New York, NY Commonwealth Fund October2000;
TI - A 2020 Vision for American Health Care
JF - Archives of Internal Medicine
DO - 10.1001/archinte.160.22.3357
DA - 2000-12-11
UR - https://www.deepdyve.com/lp/american-medical-association/a-2020-vision-for-american-health-care-ujGF2GkfBD
SP - 3357
EP - 3362
VL - 160
IS - 22
DP - DeepDyve
ER -