Correspondence
The Case for the Clinton Plan for Health Care Reform
N Engl J Med 1994; 330:1086-1088April 14, 1994
- Article
To the Editor:
Despite its impressive scope and detail, Starr's description of the Health Security plan (Nov. 25 issue)1 neglected a key element of health care reform: the content of the federally mandated minimal-benefit package. Its content will determine whether the plan can achieve its principal objectives.
One policy option that might promote agreement on a basic benefit package would be to distinguish explicitly between necessary and elective medical services and to structure the benefits differently for these two types of care. Under such a plan, medically necessary care would be covered completely, but patients would make mandatory copayments for elective procedures. For example, endoscopy would be fully covered for patients with active gastrointestinal bleeding but would require a copayment for an evaluation of simple dyspepsia. A further refinement would be to vary the copayment according to the appropriateness of the elective procedure. Patients desiring a hysterectomy for dysfunctional uterine bleeding might face a substantial copayment if they chose not to undergo a trial of hormone therapy, but the copayment might be reduced or eliminated if conservative treatment options had been exhausted. Copayments could also vary with income.
This approach ensures universal access to necessary care and offers a concrete mechanism for reducing waste and achieving discriminating use of expensive forms of medical technology. Mandatory copayments would motivate patients to weigh alternative treatment options carefully before choosing a costly procedure. Out-of-pocket copayments would also create true competition among providers who perform elective procedures, forcing down prices. Finally, this approach might facilitate political consensus on the basic benefit: Americans may support the view that whereas necessary health services are a universal right, certain elective procedures represent a commodity or privilege.
1 ReferencesCarl D. Stevens, M.D., M.P.H.
Value Health Sciences, Santa Monica, CA 904041
Starr P . The framework of health care reform. N Engl J Med 1993;329:1666-1672
Full Text | Web of Science | Medline
To the Editor:
Professor Starr suggests that competition and caps on spending will control medical inflation. They will not.
Medical inflation is driven largely by the propensity of physicians to do everything possible for more and more people, employing forms of high technology and more costly methods with diminishing returns in terms of satisfactory patient outcomes. The increasing use of organ transplantation, chemotherapy with bone marrow rescue for metastatic cancer, intensive care of premature babies, dialysis, and a host of other procedures demonstrates why medical inflation will continue.
Today, such high-cost care is rationed. Those with insurance coverage get it, and those without insurance do not. It will be only a matter of time before inflation in health care forces managed-care physicians to deny high-cost care to patients for economic reasons. This pits the patient and the patient's physician against the managed-care organization. Our courts have consistently sided with plaintiffs on these issues of coverage.
President and Mrs. Clinton and their team should bring this critical issue into the discussions -- now. The American public must reach a consensus on it. To afford a high quality of care for all our citizens, we must agree as a nation to develop policies for the equitable distribution (rationing) of extraordinarily costly care to those who, realistically, stand to gain from it. We cannot devote major resources to a few people, with only a remote possibility of success, and neglect large numbers who would benefit from simpler, more basic care.
Clifford J. Harris, M.D.
CIGNA Healthplan of Arizona, Phoenix, AZ 85029To the Editor:
The following sentences from Paul Starr's defense of the Clinton plan are quite misleading: “A single-payer system . . . would require a tax increase of unprecedented size. To transfer all private health care coverage to the federal budget would be daunting. The unbridled growth of Medicare alone poses a threat today to the federal government's solvency.”
The first two sentences imply that President Clinton's plan does not require a tax increase, whereas S. 491-H.R. 1200, the Wellstone-McDermott single-payer bill, does. Here is one definition of a tax: “a charge, usu. of money, imposed by authority upon persons or property for public purposes.”1
Clinton's plan will require all employers to buy insurance for their employees; employees will be required to pay a portion of the premium. To all but the White House and its defenders, these payments by employers and employees fit the definition of a tax. Like the single-payer taxes, this employer-employee tax will be “of unprecedented size,” and enacting it will be “daunting.”
The last sentence quoted above, about the “unbridled growth” of Medicare, requires two rejoinders. First, as every physician and hospital executive in America knows, Medicare has done at least as much to “bridle” health care spending as private-sector insurers have, if not more. Second, the “solvency” of the U.S. government cannot and never will depend on “Medicare alone” or any other program; our society's willingness to raise taxes, be it for Clinton's health plan or for Medicare, is always a determining factor.
1 ReferencesKip Sullivan, J.D.
Citizens Organized Acting Together, St. Paul, MN 55114Author/Editor Response
Dr. Starr replies:
To the Editor: The proposal of Dr. Stevens to distinguish between necessary and elective procedures and to vary copayments accordingly is eminently reasonable. Yet such a system would be complex to administer and would probably be a source of friction and controversy. If the administrative problems could be overcome, I would not rule it out as a future direction for policy that might help answer the problems raised by Dr. Harris. But for the time being, I do not see the imperative to introduce new, anxiety-provoking benefit limitations under reform. There is plenty of room to rationalize the system before we adopt any set of rationing criteria.
Mr. Sullivan's assertion that required contributions to premiums by employers and employees are tantamount to taxes flies in the face of well-established practice. No state that requires drivers to pay for automobile insurance counts the premiums as a tax. Government at all levels imposes duties (as in housing codes or product-safety regulations) that have costs; these are never counted as taxes. Today, millions of employees and employers pay premiums for private health insurance; they will continue to do so if Congress enacts the Clinton plan. There would be no reason to reclassify all such continuing payments as taxes. The crucial difference is that a taxpayer receives no direct individual benefit and has no control over the destination of tax payments. In the case of mandated insurance, however, there is a direct benefit to the individual in the form of personal coverage. Moreover, under the Clinton plan people exercise control over the use of their premium dollars by enrolling in a private health plan.
The Wellstone-McDermott bill requires a payroll tax of 8.5 percent and an income-tax increase of 2.1 percent. It turns millions of Americans from “winners” into “losers” under reform. Indeed, virtually all households with incomes of more than $50,000 stand to pay more for health coverage under such an approach. Health care reform should not be held hostage to income redistribution.
Paul Starr, M.D.
Princeton University, Princeton, NJ 08540- Citing Articles (1)
Citing Articles
1
Carl D. Stevens, Robert W. Dubois, Tania Larequi-Lauber, John-Paul Vader. (1997) Efficacy of lumbar discectomy and percutaneous treatments for lumbar disc herniation. Sozial- und Pr
ventivmedizin SPM 42:6, 367-379
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