A National Health Program for the United States: A
Reprinted from the New England Journal of Medicine
320:102-108 (January 12), 1989
Our health care system is failing. Tens of millions of
people are uninsured, costs are skyrocketing, and the
bureaucracy is expanding. Patchwork reforms succeed only in
exchanging old problems for new ones. It is time for basic
change in American medicine. We propose a national health
program that would (1) fully cover everyone under a single,
comprehensive public insurance program; (2) pay hospitals and
nursing homes a total (global) annual amount to cover all
operating expenses; (3) fund capital costs through separate
appropriations; (4) pay for physiciansÕ services and
ambulatory services in any of three ways: through
fee-for-service payments with a simplified fee schedule and
mandatory acceptance of the national health program payment as
the total payment for a service or procedure (assignment),
through global budgets for hospitals and clinics employing
salaried physicians, or on a per capital basis (capitation);
(5) be funded, at least initially, from the same sources as at
present, but with payments disbursed from a single pool; and
(6) contain costs through savings on billing and bureaucracy,
improved health planning, and the ability of the national
health program, as the single payer for services to establish
overall spending limits. Through this proposal, we hope to
provide a pragmatic framework for public debate of fundamental
health-policy reform. (N Engl J Med 1989; 320: 102-8.)
OUR health care system is failing. It denies access to many
in need and is expensive, inefficient, and increasingly
bureaucratic. The pressures of cost control, competition, and
profit threaten the traditional tenets of medical practice.
For patients, the misfortune of illness is often amplified by
the fear of financial ruin. For physicians, the gratifications
of healing often give way to anger and alienation. Patchwork
reforms succeed only in exchanging old problems for new ones.
It is time to change fundamentally the trajectory of American
medicine - to develop a comprehensive national health program
for the United States.
We are physicians active in the full range of medical
endeavors. We are primary care doctors and surgeons,
psychiatrists and public health specialists, pathologists and
administrators. We work in hospitals, clinics, private
practices, health maintenance organizations (HMOs),
universities, corporations, and public agencies. Some of us
are young, still in training; others are greatly experienced,
and some have held senior positions in American medicine.
As physicians, we constantly confront the irrationality of
the present health care system. In private practice, we waste
countless hours on billing and bureaucracy. For uninsured
patients, we avoid procedures, consultations, and costly
medications. Diagnosis-related groups (DRGs) have placed us
between administrators demanding early discharge and elderly
patients with no one to help at home - all the while glancing
over our shoulders at the peer-review organization. In HMOs we
walk a tightrope between thrift and penuriousness, too often
under the pressure of surveillance by bureaucrats more
concerned with the bottom line than with other measures of
achievement. In public health work we are frustrated in the
face of plenty; the world's richest health care system is
unable to ensure such basic services as prenatal care and
Despite our disparate perspectives, we are united by dismay
at the current state of medicine and by the conviction that an
alternative must be developed. We hope to spark debate, to
transform disaffection with what exists into a vision of what
might be. To this end, we submit for public review, comment,
and revision a working plan for a rational and humane health
care system - a national health program.
We envisage a program that would be federally mandated and
ultimately funded by the federal government but administered
largely at the state and local level. The proposed system
would eliminate financial barriers to care; minimize economic
incentives for both excessive and insufficient care,
discourage administrative interference and expense, improve
the distribution of health facilities, and control costs by
curtailing bureaucracy and fostering health planning. Our plan
borrows many features from the Canadian national health
program and adapts them to the unique circumstances of the
United States. We suggest that, as in Canada's provinces, the
national health program be tested initially in statewide
demonstration projects. Thus, our proposal addresses both the
structure of the national health program and the transition
process necessary to implement the program in a single state.
In each section below, we present a key feature of the
proposal, followed by the rationale for our approach. Areas
such as long-term care; public, occupational, environmental,
and mental health; and medical education need much more
development and will be addressed in detail in future
Everyone would be included in a single public plan covering
all medically necessary services, including acute,
rehabilitative, long-term, and home care; mental health
services; dental services; occupational health care;
prescription drugs and medical supplies; and preventive and
public health measures. Boards of experts and community
representatives would determine which services were
unnecessary or ineffective, and these would be excluded from
coverage. As in Canada, alternative insurance coverage for
services included under the national health program would be
eliminated, as would patient copayments and deductibles.
Universal coverage would solve the gravest problem in
health care by eliminating financial barriers to care. A
single comprehensive program is necessary both to ensure equal
access to care and to minimize the complexity and expense of
billing and administration. The public administration of
insurance funds would save tens of billions of dollars each
year. The more than 1500 private health insurers in the United
States now consume about 8 percent of revenues for overhead,
whereas both the Medicare program and the Canadian national
health program have overhead costs of only 2 to 3 percent. The
complexity of our current insurance system, with its
multiplicity of payers, forces U .S. hospitals to spend more
than twice as much as Canadian hospitals on billing and
administration and requires U .S. physicians to spend about 10
percent of their gross incomes on excess billing costs.1
Eliminating insurance programs that duplicated the national
health program coverage, though politically thorny, would
clearly be within the prerogative of the Congress.2 Failure to
do so would require the continuation of the costly bureaucracy
necessary to administer and deal with such programs.
Copayments and deductibles endanger the health of poor
people who are sick,3 decrease the use of vital inpatient
medical services as much as they discourage the use of
unnecessary ones,4 discourage preventive care,5 and are
unwieldy and expensive to administer. Canada has few such
charges, yet health costs are lower than in 1he United States
and have risen slowly.6,7 In the United States, in contrast,
increasing copayments and deductibles have failed to slow the
escalation of costs.
Instead of the confused and often unjust dictates of
insurance companies, a greatly expanded program of technology
assessment and cost-effectiveness evaluation would guide
decisions about covered services, as well as about the
allocation of funds for capital spending, drug formularies,
and other issues.
PAYMENT FOR HOSPITAL SERVICES
Each hospital would receive an annual lump-sum payment to
cover all operating expenses - a "global" budget.
The amount of this payment would be negotiated with the state
national health program payment board and would be based on
past expenditures, previous financial and clinical
performance, projected changes in levels of services, wages
and other costs, and proposed new and innovative programs.
Hospitals would not bill for services covered by the national
health program. No part of the operating budget could be used
for hospital expansion, profit, marketing, or major capital
purchases or leases. These expenditures would also come from
the national health program fund, but monies for them would be
Global prospective budgeting would simplify hospital
administration and virtually eliminate billing, thus freeing
up substantial resources for increased clinical care. Before
the nationwide implementation of the national health program,
hospitals in the states with demonstration programs could bill
out-of-state patients on a simple per diem basis. Prohibiting
the use of operating funds for capital purchases or profit
would eliminate the main financial incentive for both
excessive intervention (under fee-for-service payment) and
skimping on care (under DRG-type prospective-payment systems),
since neither inflating revenues nor limiting care could
result in gain for the institution. The separate appropriation
of funds explicitly designated for capital expenditures would
facilitate rational health planning. In Canada, this method of
hospital payment has been successful in containing costs,
minimizing bureaucracy, improving the distribution of health
resources, and maintaining the quality of care.6-9 It shifts
the focus of hospital administration away from the bottom line
and toward the provision of optimal clinical services.
PAYMENT FOR PHYSICIANS' SERVICES, AMBULATORY CARE, AND
MEDICAL HOME CARE
To minimize the disruption of existing patterns of care,
the national health program would include three payment
options for physicians and other practitioners:
fee-for-service payment, salaried positions in institutions
receiving global budgets, and salaried positions within group
practices or HMOs receiving per capita (capitation) payments.
The state national health program payment board and a
representative of the fee-for-service practitioners (perhaps
the state medical society) would negotiate a simplified,
binding fee schedule. Physicians would submit bills to the
national health program on a simple form or by computer and
would receive extra payment for any bill not paid within 30
days. Payments to physicians would cover only the services
provided by physicians and their support staff and would
exclude reimbursement for costly capital purchases of
equipment for the office, such as CT scanners. Physicians who
accepted payment from the national health program could bill
patients directly only for uncovered services (as is done for
cosmetic surgery in Canada).
Institutions such as hospitals, health centers, group
practices, clinics serving migrant workers, and medical home
care agencies could elect to receive a global budget for the
delivery of outpatient, home care, and physicians' services,
as well as for preventive health care and patient-education
programs. The negotiation process and the regulations covering
capital expenditures and profits would be similar to those for
inpatient hospital services. Physicians employed in such
institutions would be salaried.
HMOs, group practices, and other institutions could elect
to be paid fees on a per capita basis to cover all outpatient
care, physicians' services, and medical home care. The
regulations covering the use of such payments for capital
expenditures and for profits would be similar to those that
would apply to hospitals. The capitation fee would not cover
inpatient services (except care provided by a physician),
which would be included in hospitals' global budgets.
Selective enrollment policies would be prohibited, and
patients would be permitted to leave an HMO or other health
plan with appropriate notice. Physicians working in HMOs would
be salaried, and financial incentives to physicians based on
the HMO's financial performance would be prohibited.
The diversity of existing practice arrangements, each with
strong proponents, necessitates a pluralistic approach. Under
all three proposed options, capital purchases and profits
would be uncoupled from payments to physicians and other
operating costs - a feature that is essential for minimizing
entrepreneurial incentives, containing costs, and facilitating
Under the fee-for-service option, physicians' office
overhead would be reduced by the simplification of billing.1
The improved coverage would encourage preventive care.10 In
Canada, fee-for-service practice with negotiated fee schedules
and mandatory assignment (acceptance of the assigned fee as
total payment) has proved to be compatible with cost
containment, adequate incomes for physicians, and a high level
of access to and satisfaction with care on the part of
patients.6,7 The Canadian provinces have responded to the
inflationary potential of fee-for-service payment in various
ways: by limiting the number of physicians, by monitoring
physicians for outlandish practice patterns, by setting
overall limits on a province's spending for physicians'
services (thus relying on the profession to police itself),
and even by capping the total reimbursement of individual
physicians. These regulatory options have been made possible
(and have not required an extensive bureaucracy) because all
payment comes from a single source. Similar measures might be
needed in the United States, although our penchant for
bureaucratic hypertrophy might require a concomitant cap on
spending for the regulatory apparatus. For example, spending
for program administration and reimbursement bureaucracy might
be restricted to 3 percent of total costs.
Global budgets for institutional providers would eliminate
billing, while providing a predictable and stable source of
income. Such funding could also encourage the development of
preventive health programs in the community, such as education
programs on the acquired immunodeficiency syndrome (AIDS),
whose costs are difficult to attribute and bill to individual
Continuity of care would no longer be disrupted when
patients' insurance coverage changed as a result of retirement
or a job change. Incentives for providers receiving capitation
payments to skimp on care would be minimized, since unused
operating funds could not be devoted to expansion or profit.
PAYMENT FOR LONG-TERM CARE
A separate proposal for long-term care is under
development, guided by three principles. First, access to care
should be based on need rather than on age or ability to pay.
Second, social and community-based services should be expanded
and integrated with institutional care. Third, bureaucracy and
entrepreneurial incentives should be minimized through global
budgeting with separate funding for capital expenses.
ALLOCATION OF CAPITAL FUNDS, HEALTH PLANNING, AND RETURN
Funds for the construction or renovation of health
facilities and for purchases of major equipment would be
appropriated from the national health program budget. The
funds would be distributed by state and regional
health-planning boards composed of both experts and community
representatives. Capital projects funded by private donations
would require approval by the health-planning board if they
entailed an increase in future operating expenses.
The national health program would pay owners of for-profit
hospitals, nursing homes, and clinics a reasonable fixed rate
of return on existing equity. Since virtually all new capital
investment would be funded by the national health program, it
would not be included in calculating the return on equity.
Current capital spending greatly affects future operating
costs, as well as the distribution of resources. Effective
health planning requires that funds go to high-quality,
efficient programs in the areas of greatest need. Under the
existing reimbursement system, which combines operating and
capital payments, prosperous hospitals can expand and
modernize, whereas impoverished ones cannot, regardless of the
health needs of the population they serve or the quality of
services they provide. The national health program would
replace this implicit mechanism for distributing capital with
an explicit one, which would facilitate (though not guarantee)
allocation on the basis of need and quality. Insulating these
crucial decisions from distortion by narrow interests would
require the rigorous evaluation of the technology and
assessment of needs, as well as the active involvement of
providers and patients.
For-profit providers would be compensated for existing
investments. Since new for-profit investment would be barred,
the proprietary sector would gradually shrink.
PUBLIC, ENVIRONMENTAL, AND OCCUPATIONAL HEALTH SERVICES
Existing arrangements for public, occupational, and
environmental health services would be retained in the short
term. Funding for preventive health care would be expanded.
Additional proposals dealing with these issues are planned.
PRESCRIPTION DRUGS AND SUPPLIES
An expert panel would establish and regularly update a list
of all necessary and useful drugs and outpatient equipment.
Suppliers would bill the national health program directly for
the wholesale cost, plus a reasonable dispensing fee, of any
item in the list that was prescribed by a licensed
practitioner. The substitution of generic for proprietary
drugs would be encouraged.
The national health program would disburse virtually all
payments for health services. The total expenditure would be
set at the same proportion of the gross national product as
health costs represented in the year preceding the
establishment of the national health program. Funds for the
national health program could be raised through a variety of
mechanisms. In the long run, funding based on an income tax or
other progressive tax might be the fairest and most efficient
solution, since tax-based funding is the least cumbersome and
least expensive mechanism for collecting money. During the
transition period in states with demonstration programs, the
following structure would mimic existing funding patterns and
minimize economic disruption.
Medicare and Medicaid
All current federal funds allocated to Medicare and
Medicaid would be paid to the national health program. The
contribution of each program would be based on the previous
year's expenditures, adjusted for inflation. Using Medicare
and Medicaid funds in this manner would require a federal
State and Local Funds
All current state and local funds for health care
expenditures, adjusted for inflation, would be paid to the
national health program.
A tax earmarked for the national health program would be
levied on all employers. The tax rate would be set so that
total collections equaled the previous year's statewide total
of employers' expenditures for health benefits, adjusted for
inflation. Employers obligated by preexisting contracts to
provide health benefits could credit the cost of those
benefits toward their national health program tax liability.
Private Insurance Revenues
Private health insurance plans duplicating the coverage of
the national health program would be phased out over three
years. During this transition period, all revenues from such
plans would be turned over to the national health program,
after the deduction of a reasonable fee to cover the costs of
General Tax Revenues
Additional taxes, equivalent to the amount now spent by
individual citizens for insurance premiums and out-of-pocket
health costs, would be levied.
It would be critical for all funds for health care to flow
through the national health program. Such single-source
payment (monopsony) has been the cornerstone of cost
containment and health planning in Canada. The mechanism of
raising funds for the national health program would be a
matter of tax policy, largely separate from the organization
of the health care system itself. As in Canada, federal
funding could attenuate inequalities among the states in
financial and medical resources.
The transitional proposal for demonstration programs in
selected states illustrates how monopsony payment could be
established with limited disruption of existing patterns of
health care funding. The employers' contribution would
represent a decrease in costs for most firms that now provide
health insurance and an increase for those that do not
currently pay for benefits. Some provision might be needed to
cushion the impact of the change on financially strapped small
businesses. Decreased individual spending for health care
would offset the additional tax burden on individual citizens.
Private health insurance, with its attendant inefficiency and
waste, would be largely eliminated. A program of job placement
and retraining for insurance and hospital-billing employees
would be an important component of the program during the
The Patient's View
The national health program would establish a right to
comprehensive health care. As in Canada, each person would
receive a national health program card entitling him or her to
all necessary medical care without copayments or deductibles.
The card could be used with any fee-for-service practitioner
and at any institution receiving a global budget. HMO members
could receive nonemergency care only through their HMO,
although they could readily transfer to the non-HMO option.
Thus, patients would have a free choice of providers, and
the financial threat of illness would be eliminated. Taxes
would increase by an amount equivalent to the current total of
medical expenditures by individuals. Conversely, individuals'
aggregate payments for medical care would decrease by the same
The Practitioner's View
Physicians would have a free choice of practice settings.
Treatment would no longer be constrained by the patient's
insurance status or by bureaucratic dicta. On the basis of the
Canadian experience, we anticipate that the average
physician's income would change little, although differences
among specialties might be attenuated.
Fee-for-service practitioners would be paid for the care of
anyone not enrolled in an HMO. The entrepreneurial aspects of
medicine - with the attendant problems as well as the
possibilities - would be limited. Physicians could concentrate
on medicine; every patient would be fully insured, but
physicians could increase their incomes only by providing more
care. Billing would involve imprinting the patient's national
health program card on a charge slip, checking a box to
indicate the complexity of the procedure or service, and
sending the slip (or a computer record) to the
physician-payment board. This simplification of billing would
save thousands of dollars per practitioner in annual office
Bureaucratic interference in clinical decision making would
sharply diminish. Costs would be contained by controlling
overall spending and by limiting entrepreneurial incentives,
thus obviating the need for the kind of detailed
administrative oversight that is characteristic of the DRG
program and similar schemes. Indeed, there is much less
administrative intrusion in day-to-day clinical practice in
Canada (and most other countries with national health
programs) than in the United States.11,12
Salaried practitioners would be insulated from the
financial consequences of clinical decisions. Because savings
on patient care could no longer be used for institutional
expansion or profits, the pressure to skimp on care would be
The Effect on Other Health Workers
Nurses and other health care personnel would enjoy a more
humane and efficient clinical milieu. The burdens of paperwork
associated with billing would be lightened. The jobs of many
administrative and insurance employees would be eliminated,
necessitating a major effort at job placement and retraining.
We advocate that many of these displaced workers be deployed
in expanded programs of public health, health promotion and
education, and home care and as support personnel to free
nurses for clinical tasks.
The Effect on Hospitals
Hospitals' revenues would become stable and predictable.
More than half the current hospital bureaucracy would be
eliminated,1 and the remaining administrators could focus on
facilitating clinical care and planning for future health
The capital budget requests of hospitals would be weighed
against other priorities for health care investment. Hospitals
would neither grow because they were profitable nor fail
because of unpaid bills - although regional health planning
would undoubtedly mandate that some expand and others close or
be put to other uses. Responsiveness to community needs, the
quality of care, efficiency, and innovation would replace
financial performance as the bottom line. The elimination of
new for-profit investment would lead to a gradual conversion
of proprietary hospitals to not-for-profit status.
The Effect on the Insurance Industry
The insurance industry would feel the greatest impact of
this proposal. Private insurance firms would have no role in
health care financing, since the public administration of
insurance is more efficient1,13 and single-source payment is
the key to both equal access and cost control. Indeed, most of
the extra funds needed to finance the expansion of care would
come from eliminating the overhead and profits of insurance
companies and abolishing the billing apparatus necessary to
apportion costs among the various plans.
The Effect on Corporate America
Firms that now provide generous employee health benefits
would realize savings, because their contribution to the
national health program would be less than their current
health insurance costs. For example, health care expenditures
by Chrysler, currently $5,300 annually per employee,14 would
fall to about $1,600, a figure calculated by dividing the
total current U .S. spending on health by private employers by
the total number of full-time-equivalent, nongovernment
employees. Since most firms that compete in international
markets would save money, the competitiveness of U .S.
products would be enhanced. However, costs would increase for
companies that do not now provide health benefits. The average
health care costs for employers would be unchanged in the
short run. In the long run, overall health costs would rise
less steeply because of improved health planning and greater
efficiency. The funding mechanism ultimately adopted would
determine the corporate share of those costs.
Health Benefits and Financial Costs
There is ample evidence that removing financial barriers to
health care encourages timely care and improves health. After
Canada instituted a national health program, visits to
physicians increased among patients with serious symptoms.15
Mortality rates, which were higher than U .S. rates through
the 1950s and early 1960s, fell below those in the United
States.16 In the Rand Health Insurance Experiment, free care
reduced the annual risk of dying by 10 percent among the 25
percent of U .S. adults at highest risk.3 Conversely, cuts in
California's Medicaid program led to worsening health.17
Strong circumstantial evidence links the poor U .S. record on
infant mortality with inadequate access to prenatal care.18
We expect that the national health program would cause
little change in the total costs of ambulatory and hospital
care; savings on administration and billing (about 10 percent
of current health spendingl) would approximately offset the
costs of expanded services.19,20 Indeed, current low
hospital-occupancy rates suggest that the additional care
could be provided at low cost. Similarly, many physicians with
empty appointment slots could take on more patients without
added office, secretarial, or other overhead costs. However,
the expansion of long-term care (under any system) would
increase costs. The experience in Canada suggests that the
increased demand for acute care would be modest after an
initial surge21,22 and that improvements in health planning8
and cost containment made possible by single-source payment9
would slow the escalation of health care costs. Vigilance
would be needed to stem the regrowth of costly and intrusive
Our brief proposal leaves many vexing problems unsolved.
Much detailed planning would be needed to ease dislocations
during the implementation of the program. Neither the
encouragement of preventive health care and healthful life
styles nor improvements in occupational and environmental
health would automatically follow from the institution of a
national health program. Similarly, racial, linguistic,
geographic, and other nonfinancial barriers to access would
persist. The need for quality assurance and continuing medical
education would be no less pressing. High medical school
tuitions that skew specialty choices and discourage low-income
applicants, the underrepresentation of minorities, the role of
foreign medical graduates, and other issues in medical
education would remain. Some patients would still seek
inappropriate emergency care, and some physicians might still
succumb to the temptation to increase their incomes by
encouraging unneeded services. The malpractice crisis would be
only partially ameliorated. The 25 percent of judgments now
awarded for future medical costs would be eliminated, but our
society would remain litigious, and legal and insurance fees
would still consume about two thirds of all malpractice
premiums.23 Establishing research priorities and directing
funds to high-quality investigations would be no easier. Much
further work in the area of long-term care would be required.
Regional health planning and capital allocation would make
possible, but not ensure, the fair and efficient allocation of
resources. Finally, although insurance coverage for patients
with AIDS would be ensured, the need for expanded prevention
and research and for new models of care would continue.
Although all these problems would not be solved, a national
health program would establish a framework for addressing
Our proposal will undoubtedly encounter powerful opponents
in the health insurance industry, firms that do not now
provide health benefits to employees, and medical
entrepreneurs. However, we also have allies. Most physicians
(56 percent) support some form of national health program,
although 74 percent are convinced that most other doctors
oppose it.24 Many of the largest corporations would enjoy
substantial savings if our proposal were adopted. Most
significant, the great majority of Americans support a
universal, comprehensive, publicly administered national
health program, as shown by virtually every opinion poll in
the past 30 years.25,26 Indeed, a 1986 referendum question in
Massachusetts calling for a national health program was
approved two to one, carrying all 39 cities and 307 of the 312
towns in the commonwealth.27 If mobilized, such public
conviction could override even the most strenuous private
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3. Brook RH, Ware JE Jr, Rogers WH, et al. Does free care
improve adults' health? Results from a randomized controlled
trial. N Engl J Med 1983; 309:1426-34.
4. Siu AL, Sonnenberg FA, Manning WG, et al. Inappropriate
use of hospitals in a randomized trial of health insurance
plans. N Engl J Med 1986; 315:1259-66.
5. Brian EW, Gibbens SF. California's Medi-Cal copayment
experiment. Med Care 1974; 12:Suppl 12:1-303.
6. Iglehart JK. Canada's health care system. N Engl J Med
1986; 315.202-8, 778-84.
7. Idem. Canada's health care system: addressing the
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8. Detsky AS, Stacey SR, Bombardier C. The effectiveness of
a regulatory strategy in containing hospital costs: The
Ontario experience. 1967-1981. N Engl J Med 1983; 309:151-9.
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public/private mix for health: the relevance and effects of
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13. Home JM, Beck RG. Further evidence on public versus
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Hyattsville, Md.: Health Resources Administration, 1977. (DHEW
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17. Lurie N, Ward NB, Shapiro MF, et al. Termination of
Medi-Cal benefits: a follow-up study one year later. N Engl J
Med 1986; 314:1266-8.
18. Institute of Medicine. Preventing Low birthweight.
Washington, D.C.: National Academy Press, 1985.
19. Newhouse JP, Manning WG, Morris CN, et al. Some interim
results from a controlled trial of cost sharing in health
insurance. N Engl J Med 1981; 305:1501-7.
20. Himmelstein DU, Woolhandler S. Free care: a
quantitative analysis of the health and cost effects of a
national health program. Int J Health Serv 1988; 18:393-9.
21. LcCIair M. The Canadian health care system. In:
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23. Danzon PM. Medical malpractice: theory, evidence, and
public policy. Cambridge, Mass.: Harvard University Press,
24. Colombotas J, Kirchncr C. Physicians and social change.
New York. Oxford University Press, 1986
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1988; 10(1):3- 7.
27. Danielson DA, Mazer A. Results of the Massachusetts
Referendum on a national health program. J Public Health
Policy 1987; 8:28-35.
*This proposal was drafted by a 30-member Writing
Committee, then reviewed and endorsed by 412 other physicians
representing virtually every state and medical specialty. A
full list of the endorsers is available on request. The
members of the Writing Committee were as follows: David U.
Himmelstein, M.D., Cambridge, Mass. (cochair); Steffie
Woolhandler, M.D., M.P.H., Cambridge, Mass. (cochair); Thomas
S. Bodenheimer, M.D., San Francisco; David H. Bor, M.D.,
Cambridge, Mass.; Christine K. Cassel, M.D., Chicago; Mardge
Cohen, M.D., Chicago; David A. Danielson, M.P.H., Newton,
Mass.; Alan Drabkin, M.D., Cambridge, Mass.; Paul Epstein,
M.D., Brookline, Mass.; Kenneth Frisof, M.D., Cleveland;
Howard Frurnkin, M.D., M.P.H., Philadelphia; Martha S. Gerrity,
M.D., Chapel Hill, N.C.; Jerome D. Gorman, M.D., Richmond,
Va.; Michelle D. Holmes, M.D., Cambridge, Mass.; Henry S.
Kahn, M.D., Atlanta; Robert S. Lawrence, M.D., Cambridge,
Mass.; Joanne Lukomnik, M.D., Bronx, N. Y.; Arthur Mazer,
M.P.H., Cambridge, Mass.; Alan Meyers, M.D., Boston; Pauick
Murray, M.D., Cleveland; Vicente Navarro, M.D., Dr.P.H.,
Baltimore; Peter Orris, M.D., Chicago; David C. Parish, M.D.,
M.P.H., Macon, Ga.; Richard J. Pels, M.D., Boston; Leonard S.
Rodberg, Ph.D., New York City; Jeffrey Scavron, M.D.,
Springfield, Mass.; Gordon Schiff, M.D., Chicago; Isaac M.
Taylor, M.D., Boston; Howard Waitzkin, M.D., Ph.D., Anaheim,
Calif.; Paul H. Wise, M.D., M.P.H., Boston; and William Zinn,
M.D., Cambridge, Mass.
ã Copyright, 1989, by the Massachusetts Medical Society