A Better-Quality Alternative: Single-Payer National Health
Reprinted from JAMA The Journal of the American
Medical Association September 14, 1994, Volume 272
Copyright 1994, American Medical Association.
From the Division of General Medicine/Primary Care, Cook
County Hospital, Chicago, Ill (Dr Schiff); the Division of
General Internal Medicine and the Institute for Health Policy
Studies, San Francisco General Hospital, University of
California-San Francisco (Dr Bindman); and the Department of
Health Policy and Management, Harvard School of Public Health,
Boston, Mass (Dr Brennan). Dr Bindman is a Robert Wood Johnson
General Physician Faculty Scholar.
list of the members of the working group that drafted this
report, which was then reviewed and endorsed by Physicians for
a National Health Program, a national organization
representing more than 6000 physicians, appears at the end of
Reprint requests to Physicians for a National Health Program,
29 E. Madison St., Suite 602, Chicago, IL 60602 (Dr
MISCONSTRUE US health system reform options by presuming that
"trade-offs" are needed to counter-balance the
competing goals of increasing access, containing costs, and
preserving quality.1, 2 Standing as an apparent
paradox to this zero-sum equation are countries such as Canada
that ensure access to all at a cost 40% per capita less, with
satisfaction and outcomes as good as or better than those in
the United States.3, 4 While the efficiencies of a
single-payer universal program are widely acknowledged to
facilitate simultaneous cost control and universal access,
lingering concerns about quality have blunted support for this
of paramount importance to Americans. Opponents of reform
appeal to fears of diminished quality, warning of waiting
lists, rationing, and "government control."5 Missing
from more narrow discussions of the accuracy of such charges
is a broader exploration of the quality implications of a
universal health care program. Conversely, advocates of
national health insurance have failed to emphasize quality
issues as key criteria for reform,6 often assuming
that we have "the best medical services in the
world."7 They portray reform primarily as
extending the benefits of private insurance to those currently
uninsured, with safeguards added to pre- serve quality.
disagree with both views. It is unthinkable to label our
current system as "highest quality" given its
frequent failure to provide such basic services as
immunizations or prenatal, primary, and preventive care.
Moreover, there is growing concern about quality problems with
the care that is provided. Quality problems in the current
system include denial of care, discrimination,8
disparities, geographic maldistribution,9 lack of
continuity, lack of primary care,10 inadequate or
lack of prenatal care,11 failure to provide
beneficial prevention,12 substandard/incompetent
providers,13 declining patient satisfaction and
impersonal care,14,15 iatrogenesis (negligent
adverse events),16 diagnostic errors,17
unnecessary procedures/surgery,18 sub-optimal
medication prescribing/usage,19 and neglect of
quality-of-life/psychosocial issues.20 Our
"highest-quality" complacency is especially
challenged by insights from two seemingly disparate sources:
(1) epidemiologic research based on financial claims databases
and (2) industrial quality improvement concepts pioneered in
Japan. These two sources converge around the concept of
"variations," illuminating widespread differences in
clinical practice, further challenging the cost-access-quality
trade-off assumption. Data and insights from these two new
paradigms demonstrate that better care will actually cost less
once improvements are made in care processes and clinical
system must work better to extend access and to control costs.
In this article, we argue that a single-payer national health
program provides a better framework for improving quality.
First, we briefly review requirements for quality care. Then,
we propose 10 principles that should be integral to reform
strategies to augment quality. We contrast our approach with
the current managed competition strategy,23 showing
how a single-payer system is more likely to facilitate these
10 interrelated quality features.
QUALITY? HOW CAN IT BE MEASURED?
care should result in improved health for individuals and the
entire community. It depends on knowledgeable, caring
providers who have a thorough understanding of preventive,
diagnostic, and therapeutic strategies and the link between
their application and improved health outcomes. Such
strategies need to be applied with the highest technical skill
and carried out in a humane, culturally sensitive, and
coordinated manner. Quality will suffer when any of these
components is lacking.
no single gold standard measurement of health care quality;
its assessment requires multiple perspectives. The care
provided to the population as a whole as well as to individual
patients should be evaluated because critical quality issues
may affect individuals who do not have access to medical
services. Viewpoints of providers, patients, family members,
and the community must be incorporated. Evaluated services
should not be limited to medical care but should also include
related services, such as nursing services, social services,
and community education. To judge quality, we need a
lengthened time frame that allows not only for examination of
longer-term impacts but also for changes over time in what is
considered good care. Finally, quality should be judged in the
context of costs, because when equally good care is provided
at a lower cost, more resources are available for other
consensus has emerged around many of these precepts,24,25
there is disappointment over the extent to which their
fragmented application has actually improved care.26,27
This meagerness of demonstrated benefit is especially
worrisome given providers' frustration with the time and
administrative burdens imposed by current oversight measures.
Promising efforts to operationalize these precepts on a larger
scale (ie, Agency for Health Care Policy and Research, the
Joint Commission on Accreditation of Healthcare Organizations'
Agenda for Change, and Medicare's Quality Improvement
Initiative)28 will continue to have limited success
if not linked to more fundamental changes in health care
finance and delivery. This will require health system reform
based on the application of quality assurance tools and
insights, guided by the principles outlined below.
PRINCIPLES FOR IMPROVED QUALITY
There is a profound and inseparable relationship between
access and quality: universal insurance coverage is a
prerequisite for quality care. Because quality must be population based, traditional
definitions of quality should be broadened to include the
gravest of quality deficits-denial of care.28 The
most important prerequisite for access is health insurance. To
delay universal coverage for years, as projected in the
Clinton plan and various congressional health proposals, means
the continuation of compromised quality for millions of
evidence from large observational studies underscores this
strong relationship between quality and access/ insurance
- The hospitalized uninsured are 2.3 times more likely to
suffer adverse iatrogenic events.29
- The loss of Medicaid coverage has been associated with a
10-point increase in diastolic blood pressure and a 15%
increase in the hemoglobin A1c level in
diabetic patients, increasing the odds of dying within 6
months by 40%.30
- The uninsured poor are twice as likely as those with
private insurance to delay hospital care; among those
delaying care, hospital stays are longer and death rates
- Being uninsured was associated with twice the 15-year
mortality (18.4% vs 9.6%); even after adjusting for major
health risk factors, mortality remained 25% higher.32
- Lack of health insurance is associated with failure to
receive preventive services, including blood pressure
monitoring, Papanicolaou tests, breast examinations, and
profound connection between quality and access extends far
beyond simply underserving the uninsured. Access problems
threaten quality for those with insurance who encounter delays
and overcrowding in emergency departments overflowing with
patients lacking primary care.34 For the insured,
limitations on benefits, including financial barriers (such as
co-payments, restrictions in coverage, and rationing via
administrative obstacles), increasingly obstruct care.35
Most important, quality is distorted when ability and
willingness to pay become the criteria for determining which
services are provided. Marginally effective or even harmful
treatments for the well-insured affluent take priority over
more needed and appropriate services.36
best guarantor of universal high-quality care is a unified
system that does not treat patients differently based on
employment, financial status, or source of payment.
This principle embodies Eddy's health care "golden
rule": If a service is necessary for oneself, it is
necessary for others.37 We reject the notion that
different people are entitled to a different quality of care.
quality-impairing consequences of separate classes of
insurance are illustrated by Medicaid, whose recipients,
though "insured," are often refused care or provided
substandard treatment.38 For many medical services,
access for Medicaid patients is little better than for the
uninsured (D. U. Himmelstein and S. Woolhandler, unpublished
tabulations from the 1987 National Medical Expenditures
Survey). Similarly, universally available lowest-tier
coverage, such as that proposed under managed competition,
with more or better services only for those able to afford to
upgrade their benefits, violates this principle and would
perpetuate inequalities in health care.
equality principle is a prerequisite to grapple meaningfully
with ways to control marginally effective expensive
interventions. Otherwise, limits based on ability to pay are,
by definition, discrimination against the poor.39
multitiered system, patients and providers internalize an
"everyone for himself or herself' ethic, eroding
incentives for improving the system overall.40 A
cohesive system based on fairness and equality could harness
each citizen's desires for quality care to drive system
quality upward. It would promote mechanisms for individual
complaints to be linked to system-wide improvement rather than
dissipated as special privileges. It would ensure that the
quality of the basic plan is high enough to be acceptable to
all citizens. Proposals that allow individual or corporate
"opting out" of publicly defined benefit packages
erode this quality-enhancing covenant. Hence, a single program
not only minimizes discrimination against the vulnerable but
also promotes improvement overall.
Continuity of primary care is needed to overcome fragmentation
and overspecialization among health care practitioners and
institutions. Patients need care coordinated by the primary care provider
of their choice. Whether evaluating a confused elderly patient
or discontinuing aggressive care to a patient with emphysema,
a continuing physician-patient relationship is the essential
foundation that allows physicians to practice conservative,
sensitive, appropriate, cost-effective medicine. Competitive
models that encourage patients to switch among competing plans
discourage ongoing relationships.41 Competition
also blunts incentives for prevention because the resulting
savings are likely to accrue long after the patient has
switched to a rival plan.
practitioners, we do quality work when patients can trust that
we will be available with the time, independent judgment, and
familiarity with their problems to give them skillful personal
attention. Cost-containment efforts designed to limit
utilization have counterproductively undermined this primary
caring role. Erecting financial barriers to discourage
contact, penalizing the primary practitioner for ordering
tests and consultations, and intrusive utilization review
measures have contributed to growing dissatisfaction with
primary care practice.42,43
standardized confidential electronic medical record and
resulting database are key to supporting clinical practice and
creating the information infrastructure needed to improve care
overall. Information technology should allow us to zoom in to focus on the
microdetails of why a particular clinical decision was made,
as well as give a macro-overview of disease patterns in
populations. Its memory should permit panning backward and
forward in time, seeing our own patients' past histories, as
well as aggregating data to project disease natural history
and response to interventions.
implementation of medical computing has been driven by
insurance/billing imperatives, often ignoring information
needs for improved patient care. The Institute of Medicine
Committee on Improving the Medical Record has documented the
ways that paper-based medical records and computerized
laboratory and claims data fail to coalesce into integrated
patient care records, capable not only of storing patient data
but also of improving the quality of care.44
Consider routine yet currently difficult clinical decisions,
such as whether a patient's wound requires a tetanus shot, or
a positive syphilis serology result requires treatment, or a
decreased hematocrit requires further workup. Computer
technology should permit us to track patients over time across
multiple sites and support higher-quality clinical decision
making. Its potential for real-time reminders, prescribing,
and bibliographic assistance is vast but unrealized.44,
the computer's quality support potential hinges on strong
guarantees of personal data confidentiality,44
uniformity and integrity of data systems, availability of
aggregate data in the public domain,46 and
minimization of costs, especially for software development and
data acquisition. Creating national standards for protection
of patients' privacy is one of the most important issues that
health system reform must address, yet prospects for federal
leadership appear to be confused and uncertain.47, 48
The United States lags behind other countries in developing a
secure clinical information infrastructure because it lacks a
unified approach. No public entity has sufficient scope or
authority to spearhead this project.49
lengthy section on information automation, the Clinton
proposal perpetuates the primacy of financial data to the
neglect of clinical information by calling for computerized
billing but not computerized patient care records.50
Furthermore, managed competition compromises this crucial tool
for advancing the public's health by fragmenting information
among competing health plans and creates incentives for
distortion (ie, "diagnosis creep") that arise when
data are linked to financial rewards.51
Health care delivery must be guided by the precepts of
continuous quality improvement (CQI).
Improved data combined with statistical thinking permit a more
scientific practice of medicine. Five ideas are basic to CQI22,
- Systems improvement: addressing underlying causes of
problems rather than inspecting for and micromanaging
individual practice variations.
- Teamwork and cooperation: shift from fear, individual
blame, and competition toward cooperation to improve
interactions within and between organizations.
- Overriding commitment to quality: quality should be the
foremost mission and central preoccupation of health
system leaders and reform efforts; cost savings derive
from this primary commitment to quality.
- Improvement of processes: quality can be continually
improved by study, innovation, and simplification of the
numerous small steps involved in performing daily tasks,
leading to an organizational atmosphere of experimentation
and productive change.
- Empowerment of workers and customers: frontline workers
must have the authority, resources, and statistical tools
to conduct process improvements. Patients' voices must be
amplified so that their needs can be better addressed as
the central aim of health care.
widespread endorsement of CQI belies a continuing focus on
external inspection, short-term financial gain as the measure
of success, inefficient cost-control measures, and disruptions
of physicians' relationships with patients and colleagues as
employers and insurers seek the lowest price (New York
Times. January 24, 1993:1).22, 41, 43, 54 Under
our current system, each insurer must protect its financial
stake through these shortsighted measures that disrupt overall
quality. Well situated to exercise such undesirable options,
insurers cannot risk the long-term commitments to patients and
providers, plus loss of management prerogatives, inherent in
the five elements of CQI.
individual providers' care can best be accomplished via
supporting their ability to practice quality care coupled with
pooled outcomes data and patient feedback. This contrasts to
the current punitive, exclusionary, and competitive
approaches. The thrust of CQI is to improve the norm of
performance rather than to merely identify outliers. Where
individual competence and performance deficiencies do exist,
they must be conscientiously evaluated and definitively
resolved. Continuous quality improvement creates a climate and
provides tools to accomplish this more fairly and
forums for enhanced public accountability are needed to
improve clinical quality, to address and prevent malpractice,
and to engage practitioners in partnerships with their peers
and patients to guide and evaluate care.
Patients' and practitioners' mutual de- sire to redress and
prevent suboptimal medical outcomes should make them natural
allies. Instead, we are witnessing growing antagonisms. The
narrow emphasis on antagonistic all-or-none approaches, such
as lawsuits, or exiting one plan for another, constrains
consumers from maximally exercising choices, sharing in
decision making, and being genuinely involved in oversight and
helping to pre- vent malpractice.
Harvard Malpractice Study demonstrated that one in 25
hospitalized patients suffered a disabling iatrogenic injury,
one quarter of these as a result of negligence.16
Reconciling consumers' legitimate demands to improve this
performance with the need to protect confidentiality, the need
to nurture candid professional introspection, and the cur-
rent inadequacy of outcomes data for judging quality55
poses difficult challenges. This requires trust and
cooperation. Although we believe that a no-fault approach to
malpractice is most consistent with the logic of CQI (which
seeks prevention over blame) and universal coverage (which
would already provide lifetime health benefits for iatrogenic
injuries, thus obviating the need to sue for such benefits),
additional research is needed on questions of deterrence and
the concept of informed con- sent was once foreign, today's
physicians are unaccustomed to thinking constructively about
creating a health sphere in which difficult issues and
alternatives are openly discussed. Gathering data about care
practices and turning those data into information to be shared
with peers and the public must become a key ethical duty.46,
66, 57 New vistas for more public yet scientific and
collegial oversight include designing and evaluating practice
guidelines58; evaluation of patient satisfaction,
complaint, and outcomes data, such as delayed or missed
diagnoses59; ombudsman programs; alternative ways
to adjudicate malpractice allegations16;
interactive decision-making computer technology60;
and more meaningful regulatory activities.61-64
event of a medical mishap or untimely death, patients or
relatives want an explanation and an opportunity to ask
questions and receive full and honest answers, things we often
fail to provide.65 For centuries, the autopsy has
fulfilled an important "convening" function for the
profession to engage such questions and admit mistakes
(unfortunately this valuable tool is increasingly neglected).66
Practice databases may facilitate an analogous convening forum
for bringing together the profession and the public to examine
our record, thereby fulfilling our obligations for expanded
Financial neutrality of medical decision making is essential
to reconcile distorting influences of physician payment
mechanisms with ubiquitous uncertainties in clinical medicine.
incentives may distort the quality of medical services.
Fee-for-service favors excessive use of services, while
capitation payment may encourage undertreatment.54, 67
To lessen this tendency for physician payment to distort
treatment decisions, we must strive to remove personal
financial considerations from clinical decision making.
by physicians to medical facilities from which they profit is
a particularly egregious example of a financial incentive
distorting a physician's practice. Physician ownership of
diagnostic imaging centers is associated with a referral rate
four times that of their noninvesting physician colleagues.68
Similarly deplorable are managed care arrangements that
directly tie physicians' incomes to withholding referrals for
diagnostic tests, specialty consultation, or hospitalization.
These arrangements create an unacceptable conflict between a
patient's welfare and a physician's financial interest. Even
not-for- profit physician networks, portrayed by Clinton plan
advocates as alternatives to insurance company or managed care
inducements,69 perpetuate this conflict of interest
when they make providers assume "financial risk" for
do need to make more cost-conscious and cost-efficient
decisions. However, we reject approaches that expect improved
decision making to derive from tinkering with physician
rewards. The problem is not insufficient motivation; it is
uncertainty which, as many have noted, is ubiquitous in
medicine.70 Financial incentives to manipulate
physicians to do more or less conceal rather than address our
clinical knowledge deficits. Physicians respond best to
efforts, based on their intrinsic values, that motivate and
involve them directly in improving patient care. Even when
forced to choose between maximizing patient outcomes over
their own financial gain, physicians typically choose to
recognize that financial neutrality is an ideal. No payment
mechanism completely eliminates the influence of payment on
treatment. For example, while payment by salary separates
day-to-day clinical decisions from financial considerations,
it can encourage undertreatment or the avoidance of more
complex patients who require expensive care. The current
British approach, capitation supplemented with added fees for
preventive services and complex cases, illustrates one
possible alternative.72 Such arrangements at least
channel incentives toward mutually agreed on positive
objectives rather than creating conflicts and lack of trust
that poison provider-patient relationships.
Emphasis should shift from micromanagement of providers'
practices to macroallocation decisions.
Public control over expenditures can improve quality by
promoting regionalization, coordination, and prevention. The
uncontrolled proliferation and duplication of expensive
technology in our present system, considered by some the sine
qua non of US high-quality care, both adds to cost and
detracts from quality.
example, because we have too many mammography machines, each
is underutilized. This doubles the cost of each test. As a
result, many women cannot afford screening. Thus, because we
have too many mammography machines, we have too little breast
technically complex procedures, an inverse relationship
between volume and mortality rates has generally been
observed.74 Yet, in the RAND appropriateness study,
one fourth of the surgeons performing carotid endarterectomies
did only one such procedure per year (on Medicare patients).
Three of four surgeons performed fewer than 10
endarterectomies - the average annual number performed by
these surgeons was 3.4, a number most would consider too few
to maintain proficiency.75
compete for patients by establishing competing specialized
services rather than cooperating to establish one high-quality
unit. Two decades of "regional planning" requiring
certification for more costly capital expenditures have shown
that, absent more direct financial control of capital
allocations, such regulatory efforts have not succeeded.76
toward macroallocation broadens quality horizons in many ways.
Establishing "fences" that prospectively define
available resources means that less energy and money are
wasted micro- managing each decision, and more energy is
directed toward overall quality.77 A child scolded
to clean his plate because there are children starving in
Africa may reasonably question the logic. Refusing intensive
care unit treatment to an elderly patient because the
resources could be better used for prenatal care is similarly
hard to justify if we lack a structure to redirect the
resources.78 Global budgets allow managerial
energies to be redirected away from maximizing revenue,
improving market share and expansion, toward improving
gurus rely on report cards to allow marketplace choices to
drive competition toward better quality. They overestimate the
precision of measurements at the level of the individual
provider or health plan (New York Times. March 31,
1994:A1, A11)79 as well as the higher
"leverage" potential of coordinated system
improvement. Because existing measures lack precision, cost
may end up being the only "objective" measure.
Berwick80 has argued that quality needs to be
induced rather than selected. Measuring performance ought to
be aimed more at improving quality than at lubricating
competition. Such improvement requires leadership committed to
improving each component of the system as well coordinating
its various elements.
Quality requires prevention. Prevention means looking beyond
medical treatment of sick individuals to community-based
public health efforts to prevent disease, improve functioning
and well-being, and reduce health disparities.
These simple goals, articulated in Healthy People 2000,81
remain elusive. Nine preventable diseases are responsible for
more than half of the deaths in the United States, yet less
than 3% of health care spending is directed toward prevention.82
health insurance attaches funding only to individual patients
and thus separates the funding role and control from that of
representing broader societal interests.83
Insurance companies discovered risk factors, such as
hypertension,84 yet they used this insight
primarily to exclude high-risk individuals. This fragmenting
of the community places both sick people and the social causes
of disease outside the boundaries of medical care. Although
rhetorically "prevention is cheaper than cure," many
preventive measures probably increase costs.85
This, combined with high patient turnover rates and short-term
financial orientation, gives private insurers little incentive
to invest in prevention.
care financing should facilitate problem solving at the
community level. Community-based approaches to health
promotion rest on the premise that enduring changes result
from community-wide changes in attitudes and behaviors as well
as ensuring a healthy environment.86, 87 Stores
that refuse to sell tobacco to minors and promote low-fat
foods, schools that teach avoidance of human immunodeficiency
virus infection, and a health department that can guarantee
clean air and water have a more vital role in ensuring health
than does private health insurance. According to Enthoven,88
the originator of managed competition, its "goal is to
divide providers in each community into competing economic
units." Capitation payments to competing providers, in
theory designed to motivate prevention, thus fracture the
community and make community-based interventions more
difficult because no provider has a population-based purview.
Affordability is a quality issue. Effective cost control is
needed to en- sure availability of quality health care both to
individuals and the nation.
Good-quality care should not mean expensive care; if it does,
it will not be available to most citizens. Flawed cost control
reduces quality in many ways. It diverts resources from
legitimate health needs, increases iatrogenic risks, and leads
to financial barriers to care. These harmful impacts derive
both from failure to contain costs and "side
effects" of ill-conceived cost-control measures.
multiple cost-control measures during the past two decades,
costs continue to escalate. These measures have failed to slow
growth of administrative costs, improve efficiency, curb
ineffective or marginally effective services, or rein in
excessive managerial or professional salaries or profits.89,
90 Moreover, many cost-control initiatives have
encouraged providers to discriminate against less profitable
patients and increase their focus on fiscal rather than
prevalent approach to containing costs has been patient
"cost sharing." Financial barriers have serious
quality-impairing potential unless they are adjusted to
patients' need for care and ability to pay .91,92
It is impossible to erect a barrier high enough to discourage
unnecessary care, low enough that needed care is not deterred,
and simultaneously adjusted to a patient's discretionary
income. Donabedian91 argues that "even if such
adjustments were made, financial barriers would remain too
blunt an instrument for assuring a precise calibration of care
to need." The RAND Health Insurance experiment confirmed
this, finding that "changing economic incentives can
alter the amount of care consumed, but implementing such
incentives appears to increase or decrease proportionately
both appropriate and inappropriate use."46
insurers and employers have regularly sought cheaper care and
to avoid paying beneficiaries' bills, but have rarely
advocated better-quality care for patients.93
Health reformers in the United States should heed lessons
learned in other industries. An obsession with cutting costs
rather than with quality leads to both suboptimal quality and
higher costs. Systems based on trust and common purpose
achieve far more than those based on barriers and competition.
In addition, solutions that tamper with a system, increasing
complexity, are inferior to those that simplify the way a job
reform provides a pivotal opportunity to improve the quality
of health care. We believe that a single-payer national health
program provides the most effective framework for implementing
the quality-enhancing principles discussed above.
competition strategy, such as that proposed by the Clinton
administration and debated in Congress, while designed to
provide universal access, has not demonstrated an ability to
contain cost and creates a complex structure with separate and
unequal multitiered care. Eschewing the easily enforceable
budgetary constraints of the single-payer approach
necessitates reliance on potentially damaging financial
incentives, wasteful micromanagement, and complicated
budgetary regulation to minimize spending. Accountability,
achievable only if patients are maximally empowered and
involved, is structurally nurtured by an open and publicly
controlled funding process and impeded under managed
competition by multiple intermediaries between providers and
patients. Effective implementation of computers in clinical
medicine would be retarded by pecuniary interests favoring
proprietary data and incompatible software formats and
enhanced by public development, ownership, and standards.
Global budgeting facilitates directing national resources
based on the needs derived from these epidemiologic data,
whereas competition ensures that resource allocation will
depend on profitability.
of regulation and oversight can breathe quality into a system
that is not based on caring professionals working for
patients.26 There is little empirical evidence that
report cards and regulatory constraints can reliably separate
"good" from "bad" care. The technical
capabilities of such measures are too imprecise, and
incentives for gaming are too great (New York Times. March
31, 1994:A1, A11).66, 79, 94 Such measures
encourage mindless efforts to meet concrete, but in many cases
tangential, criteria while emphasizing sanctions and policing,
which run counter to the CQI principles that empower workers
to think innovatively about processes. Regulation cannot
revitalize a system controlled by financial institutions
driven by fiscal incentives that reward both efficiency and
fraud, quality care as well as neglect of patients' problems.
More regulatory and administrative 'overhead does mean less
time and resources for patient care.
single-payer system is not a panacea for resolving these
problems. What it does offer is a framework for collectively
engaging these issues in a fair, cohesive, and effective
fashion. The 10 principles outlined above, while neither a
detailed blueprint of how a US single-payer system would work
nor a point-by-point critique of alternate reform proposals,
suggest that important opportunities to improve quality would
be compromised were the United States to settle for a managed
than being a code word for the status quo, quality must become
a pivotal guide for change. A unified system emphasizing
cooperation, democratic accountability, and explicit planning
is preferable to a fragmented approach with accountability
abdicated to success or failure in the market and planning
forsaken in favor of resource allocation based on
profitability. Only this preferred approach to system redesign
can lead us to a qualitatively better system, one that
instills a sense of ownership and pride in its patients and
Ann McKinnon for editing assistance. The 18 members of the
working group that drafted this report were as follows: Dr
Schiff (chair), Dr Bindman, Thomas Bodenheimer, MD, MPH, Dr
Brennan, Carolyn Clancy, MD, Oliver Fein, MD, Ida Hellander,
MD, David U. Himmelstein, MD, Linda R. Murray, MD, MPH, T.
Donald Rucker, PhD, Ron Sable, MD (deceased), Jeffrey Scavorn,
MD, Ronald Shansky, MD, Ellen Shaffer, MPH, David Slobodkin,
MD, MPH, Steve Tarzynski, MD, MPH, Steffie Woolhandler,MD,
MPH, and Quentin D. Young, MD.
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