Internists shake things up

January 18, 2008

In their Rx for healthcare reform, internists see a single-payer system as an option.

In the debate over healthcare reform, organized medicine, led by the AMA, has long favored a pluralistic approach, long on private involvement, short on government intervention.

Now the American College of Physicians has strayed from the established orthodoxy. In a paper released online in early December (and in the pages of the Annals of Internal Medicine this month), the ACP has put forth a number of recommendations, including one calling for universal health insurance coverage, either through a revamped pluralistic system-something along the lines of the Federal Employees Health Benefits Program (FEHB)-or, more controversially, a single-payer system. (For the full report, go to http://www.acponline.org.)

"As an individual, I might predict which way the American political system is going to go," says Tennessee internist J. Fred Ralston Jr., chair of the ACP's Health and Public Policy Committee and one of the paper's authors. "But that doesn't mean one or the other option should be ignored. We need to look at both and have a debate."

The authors remind us, for instance, that, as a percentage of GDP, the US spends more on healthcare than any other country. In 2005, that translated to $6,401 per person, while industrialized countries like Canada, France, Germany, Japan, and the UK spent roughly half that amount. And yet, as the authors make clear in their reference to a recent study by The Commonwealth Fund, on most measures of health outcomes, the US scores poorly. These include high life expectancy, low infant mortality, low preventable mortality, and a low proportion of adults living with limitations on their activities. The authors also use the Commonwealth study to underscore how poorly the US fares on a series of other "high-performing" indicators. On efficiency, for instance, the US scored dead last behind Australia, Canada, Germany, New Zealand, and the UK, in large part because, as the Commonwealth study notes, it "lags well behind other nations in the use of electronic medical records."

Lessons the US can learn

More federal funds for building "an interoperable health information technology infrastructure" is a second ACP recommendation for improving the US system. Others call for promoting patient-centered primary care, improving quality measurement, and encouraging "public and private investments in all kinds of medical research, including research on comparative effectiveness of different treatments."

Few within medicine or beyond would quibble with many of these recommendations, although people might differ on how to bring them about. ACP's call for universal coverage is another matter, though, especially when it holds out a single-payer system as one of the two viable options for achieving it. In some circles, that borders on heresy.

But with this and its other recommendations, ACP is looking to shake things up this election year. And that's why it has invited all doctors to test where the 2008 candidates stand on its reform proposals, including its call for universal coverage. (To view the six ACP "benchmarks," go to http://www.acponline.org/advocacy/election08/?hp.)

"Whatever your political persuasion," says Ralston, "no one should be interested in more of the same."