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Mohammad N. Akhter, MD, MPH¹

Requests for reprints should be sent to Mohammad Akhter, MD, MPH, American Public Health Association, 800 I St, NW, Washington, DC 20001-3710 (e-mail: mohammad.akhter{at}apha.org).

	ABSTRACT

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The American Public Health Association (APHA) has long advocated the development of a system of universal health care for all US residents. APHA has adopted several policies on this topic that stress the financing of the system of universal health care under a single-payer mechanism. However, this approach has never been adopted by US policymakers.

The need for universal health coverage in the United States is growing more acute, and failure to provide such coverage threatens the health status of the public. I propose an alternative approach to the single-payer system that is based on incremental extension of existing coverage mechanisms, accompanied by fundamental reform of the health care delivery system. This approach is in keeping with the traditional methods of policy development in the United States, and I urge APHA to assume leadership in advocating it.

	INTRODUCTION

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THE MEMBERS OF THE American Public Health Association (APHA) have had a long-standing interest in the establishment of a system of universal health care for all US residents, and they have expressed this interest through the passage of several policy resolutions on this topic. The most recent of these resolutions were passed in 1995 and 2000.^1,2 These policies call for the development of a universal system of health care with a single-payer approach to financing. This position has been maintained over the years despite the fact that it has never become the basis for successful legislative action.

Why has APHA failed to obtain adoption of its preferred position on universal health care? In my opinion, it is because some of our key leaders have taken the intractable position that they are the sole possessors of truth on this issue and that the American people and their political leaders should listen to them. The fact that this line of reasoning has led to persistent rebuffs from Congress should make us aware that it is time to rethink the entire issue and develop a point of view regarding universal health care that respects the input of the other stakeholders, especially the public who will be served by the health care delivery system. Let us begin this process by reviewing the current status of health insurance coverage in the United States.

	HEALTH CARE COVERAGE IN THE UNITED STATES

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More than 38 million Americans younger than 65 years were uninsured as the new millennium began. This represented a decline of approximately 2.4 million in the number of uninsured during 1998 and 1999 owing to a robust economy and low unemployment levels.³ However, the striking economic decline that has occurred during the past 2 years will undoubtedly lead to an increase in the number of the uninsured that may well raise it beyond the peak of 43 million attained in 1998.

In addition to the lack of health insurance among nearly 15% of the population of the United States, there are major economic and racial and ethnic disparities among those who have no coverage. Nearly two thirds of the uninsured come from low-income families, and nearly three quarters of these individuals are from families with at least one full-time worker. In addition, racial and ethnic minorities constitute half of the uninsured, with the highest concentration among Hispanics.⁴

	HEALTH STATUS OF THE UNINSURED

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What are the health-related consequences for those individuals who lack adequate health coverage? A major consequence is that the uninsured do not have ready access to health care services, a situation that is compounded by the decline in "safety net" facilities and other forms of free or subsidized care. As a result, the uninsured receive less preventive care, are diagnosed at more advanced stages of disease, and tend to receive fewer definitive therapeutic interventions once a diagnosis is established.⁵ In addition, the uninsured contribute to the crowding of emergency departments whose services they inappropriately seek for both major and minor illnesses, while at the same time reducing the availability of emergency services for the entire population.

The lack of health insurance coverage also has a negative impact on an individual’s health and economic status. It is estimated that if uninsured individuals could obtain health insurance, their mortality rates would be reduced by 10% to 15%, their educational attainment would increase, and their annual earnings would rise by 10% to 30%.⁵ In addition, the higher rates of morbidity and mortality among the uninsured reduce the health status of the entire population and make it less able to compete in the modern world.

	NEED FOR UNIVERSAL HEALTH CARE

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There is widespread agreement that the solution to lack of access to quality health care by a large fraction of the US population is the development of a system of comprehensive health care coverage for all Americans. This has been an objective of successive US presidents for many years, dating back to the Truman administration. The most ambitious and comprehensive efforts were made by the Clinton administration in the early 1990s (the Clinton plan was introduced to Congress as the Health Security Act of 1993), and like all previous presidential initiatives, this effort failed. The reasons for these failed efforts are multiple and complex, but it is clear the intense political action undertaken by many competing special interest groups was a major contributing factor. Furthermore, none of the proposed solutions had the consistent and widespread public support that might have overcome the efforts of the special interests.

Despite past setbacks, now is the time to take a fresh look at the possible routes to universal health coverage, including approaches to this goal taken by other countries. A forum on 6 countries’ approaches to health care reform is presented in this issue of the Journal,^6–11 along with a discussion of lessons learned by the United States from other countries’ experience.¹² In each instance there is a strong role of government in the development, operation, and funding of the health care delivery system. It is also of interest to note that most of these systems were rated as being more cost-effective than the health care delivery system in the United States by a recent World Health Organization study.¹³ All of the health care delivery systems discussed provide a wide array of health care services, including preventive and curative care, and do so at a cost to the sponsoring governments and the public that is modest compared with the annual expenditures for health care in the United States.

How useful are any of these health systems as a role model for US health care reform? Certainly there is much that can be learned from them. However, it should be recognized that there is a certain amount of turbulence in a number of these systems, and it would be helpful to understand the reasons for it so as to avoid importing dysfunctional practices into the United States.

An indicator of this turbulence is the finding of discrepancies between the rankings of the efficiency and effectiveness of a country’s health care systems in the World Health Organization study and the levels of satisfaction expressed by individuals who use these systems.¹⁴ Another indicator is the major and continuing emphasis among political leaders on health system reform in a number of countries with favorably rated delivery systems.^15,16

	INCREMENTAL REFORM OF THE US HEALTH CARE SYSTEM

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Instead of relying on models from other countries, I believe that the most effective way to reform the US health care system is to build on its existing structures and institutions by an incremental process of change. A number of observers, including Kahn and Pollock, have recommended that the health care reform effort be spearheaded by a coalition of stakeholders from across the political spectrum, and that efforts of this coalition be focused on that segment of the population that is most in need of assistance (i.e., low-income workers).¹⁷ In addition, they and others have suggested that planning efforts build on insurance coverage systems that exist at present, such as Medicaid, the State Children’s Health Insurance Program (SCHIP), and Medicare.

Would a proposed incremental expansion of Medicaid, SCHIP, and Medicare be politically acceptable in the United States at this time? As usual, the devil will be in the details. As previously mentioned, US citizens have not supported a massive reorganization of their health care delivery system in the past. Furthermore, the political strength of many of the stakeholders in health care delivery, such as providers, insurance companies, pharmaceutical manufacturers, and hospitals, can be expected to resist drastic system changes, even in the face of widespread public support for such changes. Nevertheless, expanding existing mechanisms for providing health care coverage to include the 15% of US residents who are currently uninsured would appear to be more likely to gain widespread stakeholder acceptance than attempting to construct an entirely new system.

It is time for public health to take a serious look at the current political environment, the traditions of our nation, and the interests of the stakeholders in health care and to develop a policy on universal health care coverage that is compatible with these considerations. It seems clear that such a policy would advocate expansion of Medicaid, SCHIP, and Medicare on an incremental basis until all US residents are covered by health insurance. Simultaneously, there should be a strong effort to change the nation’s health care delivery system so that it can better meet the needs of those it serves.

	PUBLIC HEALTH’S CONTRIBUTIONS TO REFORM

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Beyond developing such a policy, where can the field of public health and its practitioners most effectively contribute to the reform of the nation’s health care system? Three areas of involvement that seem to be highly appropriate for public health at this time are as follows:

1. Creating a seamless system of health care delivery that provides comprehensive preventive and curative services in a user-friendly format.
   
2. Working with the other major stakeholders in health to develop a timetable and a system that will provide health care insurance coverage for all residents of the United States. As part of this effort, we in public health should be the leaders in helping to develop consensus positions on the major issues among all stakeholders.
   
3. Providing leadership in the development of a grassroots campaign for reform of the health care delivery system and the provision of health insurance coverage that is designed to win the support of the majority of residents of the United States and their elected representatives.
   

	SUMMARY

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The US health care delivery system is in a state of crisis. It is unable to provide even basic coverage for millions of residents even though it is the most expensive system in the developed world. Other countries have, in general, been more successful than the United States in providing comprehensive health care for their citizens, and they have done so at a lower cost.

In seeking reform of health care delivery in the United States, the approach that appears most likely to succeed is one that builds in an incremental fashion on the health insurance mechanisms that already exist. Adopting this approach and working with the other stakeholders in health is more likely to achieve a successful result in the current political and economic climate than demanding that a totally new system be constructed and implemented.

Adopting the incremental approach to health care reform will not be easy. The fact that there are many powerful stakeholders whose input must be considered in the reform effort suggests that a sustained grassroots effort should be developed to advocate reforms that are demanded and supported by a majority of the public. The public health establishment has an important role in developing and leading this grassroots effort. I am confident that we will rise to the challenge and thereby help ensure an improved health status for future generations.

	Footnotes

 
Peer Reviewed

Accepted for publication August 9, 2002.

	References

TOP ABSTRACT INTRODUCTION HEALTH CARE COVERAGE IN... HEALTH STATUS OF THE... NEED FOR UNIVERSAL HEALTH... INCREMENTAL REFORM OF THE... PUBLIC HEALTH’S... SUMMARY References

 
1. APHA policy statement 9502: toward a comprehensive, universal national health program. Am J Public Health.1996;86:454–455.

2. APHA policy statement 20007: support for a new campaign for universal health care. Am J Public Health.2001;91:490–491.[Free Full Text]

3. Kaiser Commission on Medicaid and the Uninsured. Health Insurance Coverage in America: 2000 Data Update. Washington, DC: The Henry J. Kaiser Foundation Family Foundation; 2002.

4. Hargraves JL. The Insurance Gap and Minority Health Care, 1997–2001. Washington, DC: Center for Studying Health System Change; June 2002. Tracking report no. 2. Available at: http://www.hschange.org/CONTENT/443/443.pdf (PDF file). Accessed October 8, 2002.

5. Hadley J. Sicker and Poorer: The Consequences of Being Uninsured Washington, DC: Kaiser Commission on Medicaid and the Uninsured; 2002.

6. Deber RB. Rekindling reform: lessons from Canada. Am J Public Health.2003;93:20–24.[Abstract/Free Full Text]

7. Light DW. Universal health care: lessons from the British experience. Am J Public Health.2003;93:25–30.[Abstract/Free Full Text]

8. Rodwin VG. The health care system under French national health insurance: lessons for health reform in the United States. Am J Public Health.2003;93:31–37.[Abstract/Free Full Text]

9. Lee J-C. Health care reform in South Korea: success or failure? Am J Public Health.2003;93:48–51.[Abstract/Free Full Text]

10. Elias PEM, Cohn A. Health reform in Brazil: lessons to consider. Am J Public Health.2003;93:44–48.[Abstract/Free Full Text]

11. Altenstetter C. Insights from health care in Germany. Am J Public Health.2003;93:38–44.[Abstract/Free Full Text]

12. Brown LD. Comparing health systems from four countries: lessons for the United States. Am J Public Health.2003;93:52–56.[Abstract/Free Full Text]

13. The World Health Report 2000—Health Systems: Improving Performance. Geneva, Switzerland: World Health Organization; 2000.

14. Blendon RJ, Kim M, Benson JM. The public versus the World Health Organization on health system performance. Health Aff.2001;20(3):10–20.[Abstract/Free Full Text]

15. Saltman RB, Figueras J. Analyzing the evidence on European health reforms. Health Aff.1998;17(2): 85–108.[Abstract]

16. Klein R. Why Britain is reorganizing its National Health Service—yet again. Health Aff.1998;17(4):111–125.[Abstract]

17. Kahn CN III, Pollack RF. Building a consensus for expanding health coverage. Health Aff.2001;20(1):40–48.[Abstract/Free Full Text]

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