Correspondence

Health Care Reform and the American Medical Association

N Engl J Med 1993; 328:1201-1202April 22, 1993

Article

To the Editor:

We have two major reservations about the article by Ginzberg entitled “Health Care Reform -- Where Are We and Where Should We Be Going?” (Oct. 29 issue).1 The American Medical Association is a leading proponent of major reform of the American health care system. The author ignores the association's efforts toward reforming the health system and concludes, without basis, that global budgeting is the answer to the problems of our health care system. The association's proposal for reform -- Health Access America -- has been contributing for almost two years to the national public-policy debate about how to make affordable health care available to all Americans.

When the American Medical Association began working on the issue of access, discussions of health care were hardly a whisper in the public-policy arena. In the early 1980s the association convened a consensus-building convocation of business, labor, government, hospitals, and physicians. The resulting report was called “A Health Policy Agenda for the American People,” but not many were listening then, and the volume was still turned low in the spring of 1990 when Health Access America was introduced. Now, widespread agreement on the need for change seems apparent.

The American Medical Association believes that a strategy of strengthening market forces is the best way to contain health care costs. It strongly opposes a national ceiling on health care spending, otherwise known as global budgeting. Global budgeting would inevitably result in rationing as budget limits were reached, thereby compromising the physician's role as patient advocate. The manner of determining the total amounts for health care spending is arbitrary, with unpredictable consequences for patients and physicians.

The American Medical Association is trying to stimulate the needed fundamental changes that are in the best interests of both patients and physicians. Health Access America effectively addresses the problems of availability and affordability while maintaining the integrity of the private-public partnership in our health care system. The association's market-based approach seeks to retain the superior aspects of the American health care system while making the fruits of that system available to all.

James S. Todd, M.D.
American Medical Association, Chicago, IL 60610

1 References

1. 1

   Ginzberg E. Health care reform -- where are we and where should we be going? N Engl J Med 1992;327:1310-1312
   Full Text | Web of Science | Medline

Author/Editor Response

Dr. Ginzberg replies:

To the Editor: It is difficult to comment on Dr. Todd's concern that I ignored the efforts of the American Medical Association toward health-system reform. I did not deal explicitly with the health-reform proposals of any organization, but had I directed my attention to the American Medical Association I would have been highly critical, not because of its recommendation to increase access for the uninsured but because it “believes that a strategy of strengthening market forces is the best way to contain health care costs.” In my view there is little in economic theory or in recent U.S. experience that would support such a conclusion. I am convinced that it is doomed to fail, a view shared by the nation's two largest medical specialty societies, the American College of Physicians and the American Academy of Family Physicians.

Dr. Todd is surely correct in his second observation that “global budgeting would inevitably result in rationing as budget limits were reached.” But it is exactly for that reason that I favor it as a necessary first step on the long road to constructive health care reforms. To an economist, the availability of dollars must always set limits. Such limits are needed for the efficient provision of medical care, as in the ongoing production and distribution of all other goods and services.

Since the late 1960s we have seen a dissociation between dollars and medical care, but that era is now drawing to a close. Clearly, physicians, patients, and the public will be seriously discomfited as dollar constraints reemerge. But their discomfiture would be very much greater if the dissociation were permitted to continue.

Eli Ginzberg
Eisenhower Center for the Conservation of Human Resources, New York, NY 10027