Public Citizen Health Letter
A new study of U.S. physicians has found, contrary to previous opposition by doctors, that almost 60 percent of physicians support legislation to establish national health insurance.
In the United States, proposals for national health insurance have usually been opposed if not undermined by organized medicine. But that has not always been the case. In 1915, when the possibility of sickness insurance was first proposed by the American Association for Labor Legislation-a coalition of academicians, businessmen, and labor leaders-the American Medical Association supported the idea. But by 1917, following the Russian Revolution and the entry of the U.S. into World War I, this support had languished and most states lost interest in reforming the payment of care.
When the idea of national health insurance resurfaced during the first Franklin D. Roosevelt administration, the times seemed ripe for reform. Still, FDR felt that economic security was more important than health insurance, and used his political capital to press for the former. Although the Committee on the Costs of Medical Care had issued its report in 1932 supporting health reform and the American Federation of Labor pressed for universal health coverage, the virulent opposition of the AMA and the more subtle nudging of Dr. Harvey Cushing (an FDR in-law) led the President to skirt the issue. The Social Security Act therefore deliberately excluded health insurance.
In 1948 President Harry S Truman officially endorsed national health insurance. Again, the political climate did not favor his views. The combined effect of Cold War ideology and the witch hunts of Wisconsin senator Joseph McCarthy, who saw communists lurking everywhere, helped squash any possibility of reform. During this period, the AMA developed a powerful war chest that helped defeat 80 percent of pro-health insurance legislators in 1950.
The AMA was therefore armed and ready when a national health insurance plan for the elderly, Medicare, was proposed. While organized medicine recognized a need to cover the elderly and was not entirely opposed to the legislation, it was able to influence the agenda and protect fee-for-service. In the end, physicians ended up as winners, with more covered patients and a fee schedule that reflected their interests.
Sporadic attempts at major health reform during the Nixon years did not prosper, even though Senator Kennedy proposed a national health insurance plan with a single government payer as in Medicare. It was not until 1993 and 1994 and the first Clinton administration that national health insurance was once again under serious consideration. Although at first blush it seemed that the planets had aligned to support the enactment of a national health plan, any semblance of consensus quickly fell apart following a very cumbersome process. The deliberations were orchestrated by several health insurance companies, led by the First Lady, excluded Congress, and were perceived as secretive, all fatal flaws that jeopardized political success. The outcome was equally dysfunctional, producing an acronym-studded, complicated plan that defied sound bites and even reasonable political debate. In the end, the plan was torpedoed by the insurance companies, who launched a much more effective publicity campaign against the plan. The public understood the ads a lot better than they grasped the proposed reform, thereby assuring that national health insurance was a taboo subject for the remainder of the Clinton years.
It is against this backdrop that the current debate must be seen. As all presidential candidates once again approach the subject of health reform, they know that they must mobilize support beforehand if any proposal is likely to be approved. This time, not only is the medical profession failing to oppose national health insurance, but the majority is actually supporting a national health scheme. A national survey conducted by two faculty members of the Indiana University School of Medicine found that 59 percent of respondents supported legislation to establish national health insurance (28 percent “strongly” and 31 percent “generally”). The survey had a 51 percent response rate, but respondents did not differ significantly from non-respondents with respect to sex, age, type of doctoral degree, or specialty. Support for national health insurance varied by specialty. Psychiatrists were the most supportive, with 83 percent in favor. These were followed by pediatric subspecialists (71 percent), emergency medicine physicians (69 percent), general pediatricians (65 percent), general internists (64 percent), family physicians (60 percent) and general surgeons (55 percent). The only specialties in which less than half of those responding supported national health insurance were the surgical subspecialties, anesthesiology, and radiology.
The current survey, which was published in the Annals of Internal Medicine, replicates a 2002 survey, when 49 percent of respondents supported the establishment of national health insurance. What, then, accounts for the rise in support? The survey does not provide any clues, but we can speculate on some of the reasons:
- There may be a difference in the physician pool, with new entrants to the medical profession being more accepting of change than those that have retired, who most likely entered the profession when solo practice and fee-for-service were the dominant modalities.
- Physicians are more aware of the 47 million Americans who lack health insurance, a fact that is widely publicized by the AMA, among others.
- National health insurance has become increasingly attractive at a time of dwindling employerbased coverage, lagging Medicaid fees, and ever more complicated reimbursement systems required by private insurers.
- Physicians are all too cognizant of the fact that international rankings show the United States to be #1 only in how much it spends, lagging in every other indicator of health service access and health status outcome.
While national health insurance is not synonymous with a single-payer system, it is but a short step for support for the former to result in advocacy for the latter since it is not possible to have national health insurance in this country and yet retain the wasteful private health insurance industry. U.S. physicians just need to recognize that the high administrative costs of current U.S. health care are neither in their own nor in their patients’ interests. At present more than half of all Americans support a single –payer system in which all Americans would have their health expenses covered by a taxpayerfinanced government plan. Given the present levels of discontent with how health services are delivered and paid, change is likely. As Arnold Relman has framed the choice, physicians will have to decide if they cast their lot with the multiple insurers to which they devote too much time and paperwork, or with their consciences, their patients, and the standards of their professional peers.