Liberal Benefits, Conservative Spending
Reprinted from JAMA. The Journal of the American Medical
Association May 15, 1991, Volume 265 Copyright 1991, American
From Physicians for a National Health Program, Cambridge,
Mass (Drs Grumbach, Bodenheimer, Himmelstein, and Woolhandler);
the Institute for Health Policy Studies (Dr Grumbach) and the
Department of Family and Community Medicine, University of
California, San Francisco (Drs Grumbach and Bodenheimer); the
Department of Medicine, the Cambridge (Mass) Hospital and
Harvard Medical School (Drs Himmelstein and Woolhandler); and
the Public Citizen Health Research Group, Washington, DC (Dr
Himmelstein) Dr Grumbach is a Pew Health Policy Fellow.
Reprint requests to Physicians for a National Health
Program, 1493 Cambridge St, Cambridge, MA 02139 (Dr Grumbach)
The Physicians for a National Health Program proposes to
cover all Americans under a single, comprehensive public
insurance program without copayments or deductibles and with
free choice of provider. Such a national health program could
reap tens of billions of dollars in administrative savings in
the initial years, enough to fund generous increases in health
care services not only for the uninsured, but for the
underinsured as well. We delineate a transitional national
health program budget that would hold overall health spending
at current levels while accommodating increases in hospital
and physician utilization. Future national health program
spending would be indexed to the growth in gross national
product adjusted for demographic, epidemiologic, and
technologic shifts. Financing for the national health program
would transfer funds into the public program without
disrupting the general pattern of current revenue sources. We
suggest a funding package that would augment existing
government health spending with earmarked health care taxes.
Because these new taxes would replace employer-employee
insurance premiums and substantial portions of current
out-of-pocket expenditures, they would not increase health
costs for the average American.
THE AMERICAN approach to financing health care has gone
awry. From physicians to patients, from The Heritage
Foundation to the AFL-CIO, there is agreement that the system
needs reform. But what kind of reform? Although all concur
that the system is ailing, proposals diverge in their
therapeutic approach. Many advocate adjustments of familiar
regimens: larger doses of employment-based insurance and
greater infusions of public funds to expand Medicaid or to
subsidize risk pools for the uninsured.1-4 Because
such measures do not confront the interdependent problems of
rising costs and declining access, they cannot ensure health
services to all at a cost the nation can afford. A lasting
remedy requires basic restructuring of the way we pay for
The Physicians for a National Health Program plan would
cover all Americans under a publicly administered,
tax-financed national health program (NHP). A single public
payer would replace the present array of more than 1500
private insurers, Medicaid, and Medicare. A unitary program
could initially pay for expanded care out of administrative
savings without adding new costs to the overall health care
budget and would establish effective mechanisms for long-term
cost control. Although consolidation of purchasing power in a
public agency may cause apprehension among some physicians,
the program could free them from the myriad administrative
intrusions that currently plague the practice of medicine.
STRUCTURE OF THE NHP
We have previously described the design of the NHP in some
detail.7, 8 It would create a single insurer in
each state, locally controlled but subject to stringent
national standards. States could experiment with the precise
structure of the single insurer. Some may place it within a
government agency, while others may choose a commission
elected by the citizens or appointed by provider and consumer
Everyone would be fully insured for all medically necessary
services including prescription drugs and long-term care.
Private insurance duplicating NHP coverage would be
proscribed, as would patient copayments and deductibles.
Physicians and hospitals would not bill patients directly for
covered services. Hospitals, nursing homes, and clinics would
receive a global budget to cover operating expenses, annually
negotiated with the state health plan - based on past
expenditures, previous financial and clinical performance,
projected changes in cost and use, and proposed new and
innovative programs. Itemized patient-specific hospital bills
would become an extinct species. No part of the operating
budget could be diverted for hospital expansion, profit,
marketing, or major capital acquisitions. Capital expenditures
approved by a local planning process would be funded through
appropriations distinct from operating budgets.
Fee-for-service practitioners would submit all claims to
the state health plan. Physician representatives (probably
state medical societies) and state plans would negotiate a fee
schedule for physician services. The effort and expense of
billing would be trivial: stamp the patient's NHP card on a
billing form, check a diagnosis and procedure code, send in
all bills once a week, and receive full payment for virtually
all services - with an extra payment for any bill not paid
within 30 days. Gone would be the massive accounts receivables
and the elaborate billing apparatus that now beleaguer private
physicians. Alternatively, physicians could elect to work on a
salaried basis for globally budgeted hospitals or clinics, or
in health maintenance organizations capitated for all
COSTS OF THE NHP
To estimate total costs, we start by using the Health Care
Financing Administration's projection of 1991 costs under
current policies as our "baseline" figure. The
Health Care Financing Administration estimates that $567
billion will be spent on personal health care services and
products in 1991, excluding nursing home costs and insurance
overhead and profits (Table 1).9 (Although
long-term care is covered by the NHP, we have omitted these
costs to permit comparison with other acute care proposals.)
Universal coverage should increase the use of health
services by the uninsured. According to the Lewin/ICF Health
Benefits Simulation Model, approximately $36 billion of the
$567 billion in 1991 spending projected under current policies
will be accounted for by care for the uninsured, including
free care at public hospitals, uncompensated care at private
facilities cross-subsidized by insurance revenues, and
services purchased out-of-pocket. The Lewin/ICF model
estimates that an additional $12.2 billion would be required
to increase the utilization by the uninsured to levels
commensurate with those of the insured (Needleman et al10
and J. Sheils, oral communication, October 1990).
The NHP will not only assist the uninsured, but will also
cover services (eg, preventive) and payments (eg, deductibles)
that many insurers currently exclude. Would this more
extensive coverage "induce" a surge of utilization
among those currently insured? The RAND Health Insurance
Experiment found that costs for persons assigned to a plan
with no cost sharing were approximately 15% higher than the
age-adjusted, per capita health care expenditures for the
United States as a whole." However, a more natural
experiment, a study before and after the implementation of an
NHP in Quebec, failed to detect the overall utilization surge
predicted by the RAND experiment.12, 13 Although
the use of physician services in Quebec rose among those with
lower incomes, the increase was counterbalanced by a decrease
in utilization among the affluent. The net effect was
convergence of utilization rates (adjusted for health status)
among income groups, with no change in the overall rate.
Would an across-the-board increase in utilization be
desirable? In the RAND experiment, lower-income patients with
medical problems who received free care had better outcomes
than those in cost-sharing plans.14 At the same
time, many medical services currently provided are of no or of
extremely marginal benefit,15-17 and it is not the
intent of the NHP to inject an additional bolus of such
unnecessary care into the health care system.
All these factors make it difficult to predict the level of
overall utilization that would result from the NHP. For this
analysis, we have added on the full $12.2 billion cost of
bringing utilization rates of the uninsured up to those of the
insured. We will discuss in the "Budgeting Under the NHP"
section below how the NHP budget could also accommodate
increases in utilization among the currently insured.
Savings of the NHP
The administrative efficiencies of a single-payer NHP offer
the opportunity for large savings during the implementation of
the program.18 Providers would be relieved of much
of the expense of screening for eligibility, preparing
detailed bills for multiple payers, responding to cumbersome
utilization review procedures, and marketing their services.
In 1987, California hospitals devoted 20.2% of revenues to
administrative functions,19 in contrast to 9.0%
spent by Canadian hospitals (L. Raymer, Health and Welfare
Canada, written communication, April 1990). (These figures
exclude malpractice premium costs and administrative personnel
in clinical departments such as nursing.) The 11.2% difference
is attributable to Canada's simplified hospital payment
method, a method we propose for the United States.
Table 1 - Personal Health Care Costs for 1991, Excluding
Nursing Home Care, With and Without a National Health Program
(NHP), in Billions of Dollars*
New costs for previously uninsured
Discount for 11.2% hospital
Discount for 6.25% physician
Subtotal: Personal Health Care
Insurance administration and
Total Personal Health Care Plus
*This assumes Canadian-Ievel administrative efficiency and
changes in utilization only among the previously uninsured.
**1.4% of personal health care expenditures.
***This is the amount estimated by the Health Care Financing
Determining the potential administrative savings in
physician expenditures is more difficult. Although practice
expenses are 49% of physician gross income in the United
States and only 36% in Canada,20, 21 it is
uncertain how much of this difference is due to billing costs.
Malpractice costs for US physicians, for example, are higher
than those in Canada. We therefore extrapolated billing cost
data from a recent American Medical Association survey to
project minimum expected administrative savings in physician
expenditures.22 The average physician spent
approximately $14500 in 1988 billing Medicare and Blue Shield
alone, representing 5.5% of gross physician income. In
addition, physicians spent approximately 2.75% of their own
professional time on billing-related activities for these
claims. (The survey did not measure the costs of billing other
third parties or patients and therefore yields a low estimate
of physician billing costs.) We liberally estimate that
physician billing expenses in Canada are 1% of physician costs
and that Canadian physicians spend at the most 1% of their
time on billing (D. Peachey, MD, Ontario Medical Association,
written communication, June 1990). In sum, US billing costs
for physician time and practice expenses are at least 8.25% of
total physician expenditures in contrast to at most 2% of
Canadian physician costs. An NHP functioning at Canadian-level
administrative efficiency could save at least 6.25% of
physician costs. Most of these savings can be realized
rapidly. In the private practice of one of the authors (T.B.),
for example, the change to a single payer would allow an
immediate reduction in office payroll of 18%.
Administrative savings to hospitals and physicians function
as price discounts when calculating costs. For example, if
physicians could lower their overhead by 6.25% of gross income
by trimming billing expenses, fees could be lowered by 6.25%
and physicians would still earn the same net income for the
same volume of services. We therefore estimated the minimum
potential administrative savings in hospital and physician
expenditures to be $40 billion by discounting projected
hospital and physician costs by 11.2% and 6.25%, respectively
Additional savings accrue from the reduced administrative
"load factor" of a public plan. In 1987, the cost of
public and private insurance overhead and profits expressed as
a percent of personal health care expenditures was 5.9% in the
United States and only 1.4% in Canada.9, 23 If our
NHP operated with the efficiency of Canada's, the
administration of health insurance would cost $8 billion, less
than one quarter the $35 billion projected by the Health Care
Financing Administration in 1991.
As indicated in Table 1, the net cost of personal health
care and insurance overhead for universal coverage under the
NHP, including expanded services for the previously uninsured,
would be at most $547 billion if the system operated with the
administrative efficiency of the Canadian system. This is $55
billion less than the $602 billion that will be spent in 1991
under current policies that exclude approximately 35 million
Budgeting Under the NHP
We do not propose reducing the health care budget by $55
billion under the NHP. As noted above, we are uncertain how
utilization patterns might respond to universal, first-dollar
insurance coverage. Nor can we be completely confident that
hospitals and physicians will immediately shed their excess
administrative poundage and assume the leaner proportions
possible under a simplified payment system. We therefore
propose the following budgetary strategy for the NHP: We would
set the overall health care budget for the NHP's initial year
at the amount projected under current policies ($602 billion
if implemented in 1991). To keep expenditures within this
target, we would rely on the ability of a single payer to
allocate and enforce prospective budgets for physician and
hospital services. These budgets would challenge providers to
extract administrative savings and redirect resources into
patient care for the underserved. The budget would allow a
range of utilization responses among patients and physicians.
For example, the NHP could set total hospital operating
budgets at the Health Care Financing Administration projected
"baseline" 1991 level of $273 billion (Table 2),
though some individual hospitals' budgets might be adjusted to
reflect past underfunding or large operating surpluses. On
average, a hospital able to achieve full administrative
savings would have 11.2% of its budget to devote to more or
better clinical services. Billing personnel could be
transferred to clinical departments to perform clerical
duties, freeing up nurses for bedside care. Hospitals unable
to realize immediate administrative savings would not be
penalized in the short run. However, in the longer run, the
single payer within each state would evaluate hospitals'
clinical performance and efficiency and modify budgets, taking
account of these hospital quality measures as well as
community needs. The Canadian experience demonstrates that
such a budgeting process need not be cumbersome or expensive,
consuming less than $2 per capita in British Columbia (D.
Cunningham, British Columbia Ministry of Health, written
communication, July 1990).
Prospective budgeting of physician services under
fee-for-service methods would require expenditure targets or
caps. On average, fees would be set at 6.25% below current
levels, reflecting expected administrative savings to
physicians. The expenditure target, however, could be set at
$154 billion, 6% above the "baseline" projected
level for 1991 (Table 2). This would allow physician payments
to accommodate a net utilization increase of up to 12.25%,
sufficient to satisfy increased demand by the uninsured and
underinsured, while allowing a net increase in physician
income of 6%. A utilization increase above 12.25% would
trigger a compensatory decrease in fees to keep expenditures
within the budget target. Such a plan allows for control of
costs with a minimum of the administrative waste or
encumbrances of our current utilization review mechanisms.24
Summing the aggregate hospital operating budget of $273
billion, the physician budget of $154 billion, and the other
categories of personal health care spending and administration
would still leave total expenditures $18 billion below our
proposed $602 billion budget (Table 2). The $18 billion
balance could be used for start-up costs for the NHP, job
training and placement programs for displaced administrative
personnel, improved long-term care, and revitalized public
Table 2 - National Health Program (NHP) Budget, by Category
of Expenditure, in Billions of Dollars
Insurance administration and profits
New health initiatives and transition costs
*These are Health Care Financing Administration
**"Other" includes drugs, dental and other
professional services, and so forth.
FINANCING THE NHP
Health insurance proposals are frequently shipwrecked on
the shoals of their financing; any serious proposal must
specify a revenue package. Although the NHP would not result
in a net increase in total health care expenditures, it would
produce a major shift in payment sources toward government and
away from private insurance and out-of-pocket payments. We
emphasize that the average individual and business would not
pay more for health care under the NHP but would pay taxes
that take the place of, but do not exceed, current premium
payments and out-of- pocket costs. Moreover, with the single
payer's capacity to control inflation, individuals and
businesses should soon enjoy reductions in the rate of
increase of their health care costs.
What principle should underlie the choice of revenue
sources? Health care is only one factor - sometimes a minor
one - in the promotion and preservation of health. Poverty,
racial oppression, substance abuse, lack of education, lack of
exercise, overnutrition and undernutrition, and occupational
and environmental hazards all damage health. Some of these
factors can be influenced by society's revenue-generating
mechanisms. For example, raising excise taxes on cigarettes
and alcohol reduces their consumption and thereby improves
health, particularly among teenagers and the poor.25
On the other hand, burdening low-income families with high
payments (whether taxes, premiums, or out-of-pocket dollars)
reduces their disposable income and amplifies the ill effects
of poverty. In contrast, a system of taxes and other payments
that reduces the burden on low-income families without
impeding job formation may ameliorate poverty's health
consequences. Thus, funding mechanisms can be
"healthy" or "unhealthy."
Table 3 - Public Plan's Share of 1991 Personal Health Care
Expenditures Under National Health Program (NHP), in Billions
Covered by NHP
New health initiatives and
*These figures are based on the public share of spending
for these services in Canada. The shares are less than 100%
because certain services, such as cosmetic surgery, life
insurance examinations, and private room surcharges, are not
covered benefits.24 **These figures are based on
our "best guess" estimate, since the NHP will
provide more extensive coverage of nonhospital and
nonphysician services than do the Canadian provincial plans.
Nonprescription drugs are an example of a product in the
"other" category that will not be covered.
***A total of $93 billion of personal health care expenditures
uncovered by the NHP remain as out-of-pocket and individual
private insurance premium costs.
Health care financing in the United States is markedly
regressive and hence unhealthy. The bottom income decile
receives 1.3% of total income but pays 3.9% of health costs,
while the top income decile receives 33.8% of income and pays
only 21.7% of health costs. By comparison, in Britain the
bottom decile receives 2.3% of income and pays 1.7% of health
costs, while the top decile receives 24.9% of income and pays
25.6% of costs.26 Any departure from the existing
configuration of US health care funding should reverse the
current unhealthy pattern.
We estimate that public expenditures will account for 85%
of health spending under the NHP, requiring $509 billion in
revenues for 1991 (Table 3). We will discuss these revenues in
three categories: (1) payroll taxes, (2) general government
revenues, and (3) payments by individuals (Figure).
Employer-employee payments for group health insurance (31%
of personal health expenditures [excluding nursing-home care]27)
are, in essence, a payroll tax,28 with the money
going to an insurance company or a self-insured fund rather
than to the government. Social Security payments for Medicare
(12% of health expenditures27, 29) are also a
payroll tax. It is logical to combine these two sources of
financing, which together account for 43% of health
expenditures. To minimize economic disruption, we propose that
a similar proportion of the NHP be funded by payroll tax.
The regressive nature of a payroll tax makes it a
less-than-healthy revenue source; the employer share is often
shifted to employees as lower wages or to consumers as higher
prices.30 It should be made more progressive by
reducing the employee share for lower-wage employees, by
raising the employee share for high-income employees (eg,
eliminating the current Social Security cap), and by reducing
the employer share for small business. Employers and employees
currently pay almost 2% of total payroll for Medicare-related
Social Security taxes and approximately 10% for private health
insurance - a combined health-related payroll tax of 13%.29,
31, 32 Using Department of Commerce figures, we project
that under the NHP, an average tax rate of 9% for medium and
large employers, with an average 2% rate for employees, and
half these rates for businesses with fewer than 20 employees,
would raise $228 billion in revenues.33 These
precise tax rates are only initial suggestions and must be
negotiated with the affected parties.
General Government Revenues
Twenty-six percent of personal health expenditures
(excluding nursing-home care) comes from non-Social Security
governmental revenues at the federal, state, and locallevels.27,
29 Of this total, 51% comes from individual income
taxes, 12% from property taxes, 12% from sales taxes, 12% from
corporation income taxes, 5% from gasoline, tobacco, and
alcohol taxes, and 8% from other sources.34
Although some of these revenue sources are unhealthy, we
propose leaving them intact, adhering to the principle that
implementing the NHP should not demand radical economic
restructuring. These revenues would generate $157 billion for
the NHP in 1991.9, 29
Payments by Individuals
The third major source of health financing consists of
payments by individuals; these payments currently account for
31% of health expenditures (5% in individual insurance
premiums, 24% in out-of-pocket payments, 1% in Medicare
premiums, and 1% in other private funds).27, 29
They are the least healthy revenues because they burden
lower-income families far more than they do the affluent. To
the extent that they pay for services covered under the NHP,
they will disappear.
We propose replacing the majority of individual payments
with "healthier" revenues-taxes that reduce income
disparities and discourage the use of harmful and polluting
substances. The following measures, according to a
Congressional Budget Office study,35 would generate
$124 billion per year and could be considered as NHP tax
revenue sources: (1) a new federal income tax bracket of 38%
for families with income higher than $170, 000, (2) a cap on
mortgage interest deductions for luxury homes, (3) a 0.5% tax
on transfer of securities, (4) an increase in energy taxes to
encourage energy conservation and reduce pollution, (5) an
increase in excise taxes on cigarettes to 32 cents per pack
and on alcohol to 25 cents per ounce, (6) an excise tax on
sources of air and water pollutants, and (7) a tax on fossil
fuels to reduce carbon dioxide emissions. Although some of
these taxes are regressive, their overall effects are health
To summarize, the NHP would fund approximately 38% of
health expenditures from a payroll tax similar to current
payroll expenses for Medicare and health insurance premiums;
26% from existing federal, state, and local revenues; and 21%
from new, healthy federal tax revenues that would largely
supplant current out-of-pocket expenditures. Fifteen percent
of expenditures would remain out-of-pocket (Figure).
A majority of Americans would accept this type of tax
package if it were earmarked for health care and placed in a
health care trust fund. A 1990 poll found that 72% would
support an NHP even if it required a tax increase; however,
only 22% would pay more than $200 extra per year.36
Our proposal would not increase the sums paid for health care
by low- and middle-income groups. It is designed to minimize
winners and losers, aside from the private health insurance
Two additional principles should be incorporated in NHP
funding. Per capita health spending should be equalized
throughout the nation, with federal funds transferred to
states under formulas adjusted for age, income levels, health
status, wage, and other input costs. Finally, to protect the
NHP from annual budgetary debacles in Washington, DC, it must
be an entitlement program with a statutory expenditure floor
as well as a ceiling. In contrast to entitlement programs
restricted to poor families, the NHP would embrace the entire
population and could thus command the level of support enjoyed
by Social Security. Adequate increases in NHP funding (based
on such factors as aging of the population, epidemics,
advances in medical technology, and inflation) must be
mandated by law. As suggested in our original NHP proposal,7
an expanded program of technology assessment would help guide
In health insurance, as in many things in life, simplicity
is a virtue. The NHP's approach to universal access is simple:
every American automatically qualifies for equal,
comprehensive health insurance under a unitary public plan.
The economic premises of the NHP are also simple: funnel all
third-party payments through a single payer, thereby saving
billions of dollars in administrative costs and achieving cost
containment through global controls rather than minute
The administrative cost reductions during the NHP's initial
phase are not, as some have argued, only a one-time saving.37
Whether in Canada or New Zealand, Sweden or Britain,
single-payer systems have stabilized costs in the past decade,
while US health care inflation has been impervious to the most
earnest attempts to control costs.38-40 Economist
Robert Evans41 has concluded that
"universality of coverage and sole-source funding are, as
far as we know now, preconditions for cost control."
Global expenditure control can also enhance clinical
freedom. Under the micromanagement model of cost containment,
each of the multiple payers, lacking global budgetary levers,
resorts to intrusive patient-by-patient utilization review.24
Such day-to-day interference in medical practice is minimized
in single-payer systems.40 As John Wennberg16
The key to the preservation of fee-for-service markets, as
the Canadians seem to recognize, is not the micromanagement of
the doctor-patient relationship but the management of capacity
and budget. The American problem is to find the will to set
the supply thermostat somewhere within reason.
The NHP would benefit most Americans, though a few powerful
interest groups would suffer. It would virtually eliminate
financial barriers to care for those who are currently
uninsured and underinsured, ensure patients a free choice of
providers, ensure physicians a free choice of practice
settings, diminish bureaucratic interference in clinical
decision making, stabilize health spending, and reduce the
growing burden of health care costs for many individuals and
employers. Small-business owners who do not currently cover
their employees would face modest cost increases, though far
less than mandated by most alternative proposals. The health
insurance industry would feel the greatest impact. Indeed,
most of the extra funds needed to expand care would come from
eliminating the overhead and profits of insurance companies
and from abolishing the billing apparatus necessary to
apportion costs among the various plans. Job retraining
programs for displaced administrative and clerical personnel
would be essential.
Although few dispute the ability of the NHP to provide
universal coverage and control costs, critics have raised the
specter of rationing, pointing to queues for some high
technology services in Canada.42 We do not advocate
cutting US health spending to Canadian levels. Even with a
slower rate of growth under the NHP, US health expenditures
will remain well above those of any other nation. Deploying
our greater resources with Canadian efficiency would permit
increases in utilization and improvements in technology
without skyrocketing costs. Compared with Americans, Canadians
do, in fact, get more health care for their health care
dollar. About half of the cost differential between the two
nations is squandered on insurance overhead and paper pushing.18,
43 Stanford economist Victor Fuchs44 has
concluded that "the quantity of [physician] services per
capita is much higher in Canada than in the United States . .
. the data firmly reject the view that Canadians save money by
delivering fewer services."
Health financing reforms unable to extract administrative
savings inevitably impose added costs for expanded services.
Employer mandate proposals (eg, the Pepper Commission Plan,1
the American Medical Association's Health Access America plan,3
the National Leadership Commission's proposal,2 and
Massachusetts' Universal Health Care Law [New York Times. April
11, 1991:Al]) would leave existing insurance in place while
expanding public programs for the unemployed and requiring
employers to insure their workers. None of these plans offer
improved coverage for those currently insured, nor do they
offer new cost control mechanisms. Hence high initial costs
presage continuing inflation or far more stringent and
intrusive micromanagement - probably both. Modifications of
the employer mandate approach (eg, the UNYCare proposal in New
York State)45 that attempt to meld the cost
containment features of a single-payer system with a
continuing role for private insurance also eschew most
administrative savings, compromising the ability of such
measures to expand access without raising costs.
There is slim evidence that Enthoven and Kronick's46
"managed competition" plan - featuring competing
managed care insurers and higher patient copayments - can hold
costs in check.47 Does forcing consumers to bear
premium costs for higher-priced plans hold down overall costs
or simply segregate the market based on ability to pay? Do
low-cost plans provide care more efficiently or simply market
themselves more effectively to lower-risk subscribers? Is the
rubric "Consumer Choice Health Plan" appropriate for
a system likely to lock the vast majority of patients and
physicians into closed panel health maintenance organizations
run by insurance companies? The ultimate vision of managed
competition - a landscape dominated by a limited number of
huge health maintenance organizations managing salaried
physicians-is a more radical departure from the current health
care scene than the NHP.
The objectives of the NHP are simple: (1) to minimize
financial barriers to appropriate medical care, (2) to
distribute costs fairly, and (3) to contain costs at a
reasonable level. Once a structure is in place for meeting
these basic concerns, the medical profession and society as a
whole can move on to the more complicated questions: Which
health services truly improve the quality of life? What share
of our human and material re sources should we devote to
health care? How shall we reduce the toll now extracted by
poverty, ignorance, and addictions? By implementing a national
health program, we can turn and face the challenges ahead.
1. US Bipartisan Commission on Comprehensive Health Care. A
Call for Action. Washington, DC: The Pepper Commission on
Comprehensive Health Care; 1990.
2. National Leadership Commission on Health Care. For
the Health of a Nation. Ann Arbor, Mich: Health
Administration Press; 1989.
3. Health Access America. Chicago, Ill: American
Medical Association; 1990.
4. Kennedy E. Senate Bill S.768. November 20, 1989.
5. Woolhandler S, Himmelstein DU. Resolving the cost/access
conflict: the case for a national health program. J Gen
Intern Med. 1989; 4: 54-60.
6. Grumbach K. National health insurance in America: can we
practice with it? can we practice without it? West J Med. 1989;
7. Himmelstein DU, Woolhandler S. A national health program
for the United States: a physicians' proposal. N Engl J
Med. 1989; 320: 102-108.
8. Woolhandler S, Himmelstein DU. A national health
program: a northern light at the end of the tunnel. JAMA.1989;
9. Health Care Financing Administration. National health
expenditures: 1986-2000. Health Care Financing Rev. 1987;
10. Needleman J, Arnold J, Sheils J, Lewin LS. The Health
Care Financing Systent and the Uninsured. Washington, DC:
11. Newhouse JP, Manning WG, Morris CN, et al. Some interim
results from a controlled trial of cost sharing in health
insurance. N Eng J Med. 1981; 305: 1501-1507.
12. Enterline PE, Salter V, McDonald AD, McDonald JC. The
distribution of medical services before and after 'free'
medical care: the Quebec experience. N Engl J Med. 1973;
13. McDonald AD, McDonald JC, Salter V, Enterline P.
Effects of Quebec Medicare on physician consultation for
selected symptoms. N Engl J Med. 1974; 291: 649-652.
14. 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: 1426-1434.
15. Eisenberg JM. Doctors' Decisions and the Cost of
Medical Care. Ann Arbor, Mich: Health Administration
16. Wennberg J. Outcomes research, cost containment, and
the fear of health care rationing. N Eng J Med. 1990;
17. Chassin MR, Kosecoff J, Park RE, et al. Does
inappropriate use explain geographic variations in the use of
health care services? JAMA. 1987; 258: 2533-2537.
18. Himmelstein D, Woolhandler S. Cost without benefit:
administrative waste in US health care. N Eng J Med. 1986;
19. Aggregate Hospital Financial Data for California:
Report Periods Ending June 30, 1987-June 29, 1998.
Sacramento: California Health Facilities Commission; 1989.
20. Gonzalez ML, Emmons DW. Socioeconomic
Characteristics of Medical Practice. Chicago, Ill:
American Medical Association; 1988.
21. Iglehart J. Canada's health system faces its problems. N
Eng J Med. 1990; 322: 562-568.
22. American Medical Association. The administrative burden
of health insurance on physicians. Socioeconomic Monitoring
Survey Rep. 1989; 3: 2-4.
23. National Health Expenditures. Ottawa, Ontario:
Health and Welfare Canada; 1990.
24. Grumbach K, Bodenheimer T. Reins or fences? a
physician's view of cost containment. Health Aff 1990;
25. Last JM. Controlling the smoking epidemic. Am J Prev
Med. 1985; 1: 1-3.
26. Wagstaff A, Van Doorslaer E, Paci P. Equity in the
finance and delivery of health care: some tentative
cross-country comparisons. Oxford Rev Econ Policy. 1989;
27. Levit KR, Freeland MS, Waldo DR. National health care
spending trends: 1988. Health Aff 1990; 9(2):171-184.
28. Reinhardt UE. Health insurance for the nation's poor. HealthAff
29. Levit KR, Freeland MS, Waldo DR. Health spending and
ability to pay: business, individuals, and government. Health
Care Financing Rev. 1989; 10(3):1-11.
30. Pechman JA. Federal Tax Policy. Washington,
DC: The Brookings Institution; 1987.
31. Bergthold LA. Purchasing Power in Health. New
Brunswick, NJ: Rutgers University Press; 1990.
32. DiCarlo S, Gabel J. Conventional health insurance: a
decade later. Health Care Financing Rev. 1989;
33. Bureau of the Census. Statistical abstract of the
United States 1990. Washington, DC: US Dept of Commerce; 1990.
34. Bureau of the Census. Quarterly Summary of Federal.
State. and Local Tax Revenue. July-September 1989.
Washington. DC: US Dept of Commerce; 1990.
35. Congressional Budget Office. Reducing the Deficit:
Spending and Revenue Options. Washington. DC: The Congress
of the United States; 1990.
36. Blendon RJ. Donelan K. The public and the emerging
debate over national health insurance. N Engl J Med. 1990;
37. Aaron H. Schwartz WG. Rationing health care: the choice
before us. Science. 1990; 247: 418-422.
38. International comparisons of health care financing and
delivery: data and perspectives. Health Care Financing Rev.
1989; 10 (suppl): 1-196.
39. Pfaff M. Differences in health care spending across
countries: statistical evidence. J Health Polit Policy Law.
1990; 15: 1-24.
40. Evans RG. Lomas J. Barer ML. et al. Controlling health
expenditures: the Canadian reality. N Eng J Med.1989;
41. Evans RG. Accessible, acceptable, and affordable:
financing health care in Canada. In: The 1990 Richard
and Hinda Rosenthal Lectures. Washington. DC: Institute of
42. Board of Trustees. American Medical Association. Study
of the Canadian Health Care System. Chicago. Ill: American
Medical Association; 1989. Report V(A-89).
43. Evans RG. Split vision: interpreting cross-border
differences in health spending. Health Aff 1988;7(4):17-24.
44. Fuchs VR. Hahn JS. How does Canada do it? a comparison
of expenditures for physiciansƠ services in the United States
and Canada. N Eng J Med. 1990; 323: 884-890.
45. Beauchamp DE. Rouse RL. Universal New York Health Care:
a single-payer strategy linking cost control and universal
access. N Engl J Med. 1990; 323: 640-644.
46. Enthoven A. Kronick R. A consumer choice health plan
for the 1990s: universal health insurance in a system designed
to promote quality and economy. N Engl J Med. 1989;
320: 29-37, 94-101.
47. Jones SB. Can multiple choice be managed to constrain
health care costs? Health Aff 1989;8(3): 51-59