National health insurance - to be or not to be.

I grew up in medicine in the '60s, at a time when the American Medical Association almost bankrupted itself fighting passage and implementation of the Medicare system. The thought of a British system of national health care was considered almost anti-American and was certainly to be feared by physicians and patients alike. The most important drawbacks of such a system, according to the AMA and other opponents of Medicare, was the expected waiting time for needed services and the perceived and projected ineptness of government in administering the programs.

During the '70s and early '80s, several forces stifled discussion of "national health care." The accelerated cost to the federal government for Medicare and Medicaid worried policy makers, even though administrative costs--3 percent for Medicare and 5 percent of Medicaid--were low. Business was concerned about the threat of new taxes and the loss of service and quality that a national system might impose. Besides, health care costs represented only 5 percent of employers' payroll cost and was fully tax deductible. Heavily unionized industrial workers already had cradle-to-grave coverage, with $50 deductible and 80/20 coverage to $200 per year. The medical profession continued to lobby hard against any new or expanded coverage. Insurance companies, particularly the Blue Cross/Blue Shield organizations, were still in a monopoly position and, because of the law of large numbers, were able to share the risk even for individual insurance policies.

During the Reagan administration, social programs were cut and the number of uninsured increased. More important, the federal government shifted coverage for the chronically ill and the disabled from Medicare to employers. Medicare and Medicaid cost shifting erased profit margins that were previously used to provide care for the poor and uninsured. At the same time, hospital providers have been compelled by law and regulation to avoid the appearance of "dumping" the uninsured. Although unhappy with the current reimbursement of government programs, they are still calling for expansion of coverage for the uninsured.

In the 25 years since the Medicare legislation was passed, the practice of medicine has changed. We are long past the "Just say no" attitude of the '50s and '60s. We have "socialized medicine." Most physician practice income now comes from third-party payers, government or private. With the increase in managed care options in most locations, office visits, preventive care, and primary care procedures are all covered by insurance. The number of physicians still in traditional fee-for-service solo practice is minimal. Now the call is for a mchanism to pay for the health care costs of those who have no access to this third-party-payer-dominated system--the uninsured. A massive amount of pressure from the public, government, and the medical profession has arisen in behalf of a solution to the uninsured patient.

The causes of this large segment of uninsured Americans are varied. Small employers have had difficulty getting insurance. If available, it is very expensive. Employer-based insurance now has an average administrative overhead of 30 percent. Employment levels have remained steady in this country, but new jobs are mostly in the service area and are relatively low paying. The companies are normally small, making insurance benefits difficult to provide. A much higher percentage of manufacturing is now being subcontracted to small shops. As a result, the ranks of the uninsured now contain a significant number of employed persons. Many others, including the handicapped and patients and their dependents with preexisting health care costs, are unable to be employed because of the financial risk to prospective employers. Individual insurance is almost unavailable, even to the healthy and young. The cost to small employers and individuals is 30-70 percent higher than to large groups and coverage is inferior. The average administrative cost for individual policies is 70 percent.

Employees and unions are slowly learning about the true cost of health insurance and health care to them and are clamoring for "free," government-based care. Their experience with the Medicare program has generally been good. The politically powerful aging population sees the Medicare program as viable and continues to support its concepts.

This group wants Medicare expanded to cover long-term care and drugs. Most insurers have experienced losses and diminished profits in the health insurance area. Despite the savings that can be achieved through managed care, the high costs of bone marrow transplants and other technologies to treat cancer, AIDS, and other significant diseases make it nearly impossible to underwrite individuals and small groups. And, insurers accept severe risk if they try to avoid paying for new technologies.

In 1988, a small group of East Coast physicians formed an organization calling for a national health program. The AMA, the American society of Internal Medicine, the American College of Physicians, and other medical groups also have called for a system to reduce the number of uninsured. The May 15, 1991, issue of JAMA was dedicated to the various proposals. The idea of mandatory employer-based basic coverage is beginning to take hold. Those unable or unwilling to have insurance would be funded from a common pool. Some physicians are calling for free primary care and drug coverage without copayments or administrative hassle, with the savings being used to pay for the program. I would not be surprised to see a limitation on the amount of monthly premium that is tax deductible, which would affect almost all of the current insurance policies.

The issues of portability and preexisting conditions must also be addressed. And expansion of existing Medicaid and Medicare programs will be hampered if primary care payment issues are not remedied. Even with fee-for-service payment at the going rate of $30 per visit for routine office visit 90050, the monthly cost of all primary care is only $8 per person. Current reimbursement, even with the new Medicare relative value schedules, is inadequate to attract, product, and retain the numbers of primary physicians that are required.

Physician executives should provide leadership in this analysis and in the implementation of solutions. Rapid and unexpected government action is very possible in this biennium, especially because we are facing a presidential election. Both parties will have proposals on this issue. All physicians must take the time to be involved and informed. Change is happening. I hope this time that we involve ourselves in the solution.