Health Insurance in the USA

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Science  26 Sep 2003:
Vol. 301, Issue 5641, pp. 1813
DOI: 10.1126/science.301.5641.1813

The recent publication of a proposal endorsed by almost 8000 physicians and medical students in the United States for a national health plan that would provide universal health insurance by means of a single-payer mechanism* may mark a turning point in the national dialogue on health care. Certainly, it is a departure from the historical perception that physicians are opposed to a universal plan—especially if it involves government. To understand the significance of the current situation, a bit of history is in order.

The 20th century brought remarkable scientific developments to medicine. The emergence of research in the natural sciences early in the century transformed medical education and medical care. The institutionalization of the 4-year medical school curriculum rendered the educational process more scientific. An inevitable result of the increasing knowledge was the emergence of specialization and subspecialization of the medical profession in the latter half of the century. Much of this progress resulted from the public's belief in, and support of, biomedical research. This was manifested in the rapid and continuing federal support of the National Institutes of Health, which resulted—through a partnership with our universities and research institutes—in the remarkable expansion of our medical centers. The public-private partnership and its impact on academic medical centers has advanced medicine's scientific and technologic base and has brought significant improvements in diagnosis and treatment.

It is puzzling that a collaborative relationship among the medical profession, health institutions, universities, and government that cultivated such success in biomedical research was rejected by physicians in dealing with financial barriers and bringing access to medical care to all Americans. The organized medical profession, beginning early in the century, opposed efforts to provide equity in the provision of health services to all. One of the most bitterly fought political battles of the century about the financing of health care involved the passage of Medicare, the government health-care program for the elderly and disabled, in 1965. This happened over the vigorous though eventually ineffective opposition of organized medicine—which, as a consequence, lost much of its credibility and political influence. In the latter third of the century, no positive program for universal, comprehensive health services was enacted. That left the financing and organization of health services to market forces and converted health-care services into a for-profit arm of the insurance industry.

The lack of a comprehensive health plan leaves almost 20% of the U.S. population without health insurance. Many other individuals are inadequately insured, in a complex array of financing arrangements that result in heavy administrative costs. Because financiers have largely taken over the financing and management of health services, they have become politically potent forces in maintaining the current chaotic, but largely profitable, system. Physicians and patients alike are being held hostage to decisions of for-profit insurers.

Can health professions and institutions regain leadership in the provision of a more equitable system of medical care? In the research domain, they came to see government as a partner; in the development of services, they have come to view government as an enemy. Thus, the medical professions have largely left comprehensive solutions for medical-social issues to a political process in which they have only a marginal role. Yet, the social aspects of health care are no less important than the scientific and technical aspects. The goal should be universal coverage of high-quality care for all Americans.

Whether one agrees with the proposal of The Physicians' Working Group for Single-Payer National Health Insurance or not, it is hoped that these physicians and medical students have stimulated a dialogue in which physicians can play an important role. Physicians have a responsibility to help solve the problem of inequities in our health-care system. These problems are real and will grow larger as the years go by. Because the body politic will have to address the issues of the financing and the organization of medical care, it would be sad if America's physicians sat on the sidelines and did not take part in the dialogue.

  • * Proposal of the Physicians' Working Group for Single-Payer National Health Insurance, JAMA 290, 798 (2003).

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