Correspondence

Physicians and Health Care Reform

N Engl J Med 1994; 331:551-552August 25, 1994

Article

To the Editor:

Iglehart's recent review of the role of physicians in health care reform (March 10 issue)1 represents yet another incomplete analysis of the transformation that politics has wrought on the contemporary medical scene. In overlooking fundamental differences of political philosophy, these accounts tacitly or explicitly brand physicians who oppose reform as self-interested. Rather than view the current debate as one in which physicians who support federally mandated health care reform are pitted against those who are “more inclined... to press the pocketbook issues,” Iglehart might have focused on underlying assumptions with regard to the proper role of the federal government. There are those in the reform camp who sincerely believe that through the judicious legislation and benevolent intervention of our state and federal legislatures, the medical system can be rendered more efficient, equitable, and compassionate. By contrast, an equally sincere group of physicians view further expansion of government regulation with a skepticism verging on dread. These “libertarian” adherents believe, in varying degrees, that government is best limited to defending the Constitution, individual civil liberties, the integrity of the nation, and the freedom to be the arbiter of one's own fate in all other realms. Viewed in these terms, the President's health care reform plan has engendered a schism in the ranks of organized medicine that reflects a broader division in society as a whole. The relation of freedom to benevolent governmental regulation is central to this division and merits serious debate. Depicting opponents of federal expansion as motivated by “pocketbook issues” does nothing to further the debate and is a disservice to all sides.

Stefan M. Gorsch, M.D.
Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756-0001

1 References

1
Iglehart JK. Health care reform -- the role of physicians. N Engl J Med 1994;330:728-731
Full Text | Web of Science | Medline

Author/Editor Response

Mr. Iglehart replies:

To the Editor: Dr. Gorsch's preference seems to be for a government that sharply limits its involvement in society. Thus, he leaves the impression that if the debate concluded without broadening the role of government, physicians could declare victory and return to their practices with their autonomy intact. That prospect is impossible, because private health plans that limit a patient's selection of a doctor and that contract with only a select group of physicians are growing rapidly. A new study found that employees who enroll in such plans are more satisfied with their overall care than those with indemnity insurance1. Physicians face an essential choice between a system heavily regulated by government and one driven by entrepreneurial capitalism. Either way, government will become a more intrusive force, striving to level society's playing field. Given the American preference for private-public solutions, we are undoubtedly headed for a system that combines elements of both models. It is ironic that whereas Dr. Gorsch would strictly limit government's role, many medical organizations are seeking relief in Washington from private managed-care plans that impose limits on the choice and selection of physicians in an unfettered market2. Of course, like all private interest groups, physicians have a right to petition government in this fashion.

One of the struggles in which policy makers are engaged is the search for a formula that distributes the financial pain of universal coverage in a politically acceptable fashion. The United States stands as the outlier among nations in its failure to craft an overarching policy that would apply to the entire health care system, rather than to selected pieces of it. Of course, having no overall policy is a policy in itself. The systemic mechanisms of other countries, though imperfect, have at least enabled them to reconcile competing claims for resources in some equitable fashion, while providing nearly universal coverage. No, Dr. Gorsch, less government is not the answer. We need a responsive government that has the political will to create policies that extend insurance coverage to all Americans, demonstrating that in matters of sickness we can indeed be our brother's keeper.

John Iglehart
12008 River Rd., Potomac, MD 20854

2 References