"Defined contribution is the only answer we have for taking the next step in reform, at least on the financing side," Field said. "We tried managed care, which seems to have wrung out all the savings that it can and which antagonized enough people with its often-steamroller techniques. And now we're seeing gigantic premium increases, which is what managed care was designed to prevent, so we know something's not right. Having tried fee-for-service and managed care and having rejected for the time being a comprehensive national plan, we're looking at the idea of defined contribution plans or putting the ball in the hands of patients. We tried putting the ball in hands of the doctors, and they ran up costs. We put the ball in the hands of the insurance industry, and they antagonized everyone and interfered with care. Perhaps the patients can act as consumers do in other types of markets and make intelligent choices."
Young told PT that PNHP supports a single-payer system funded by taxes that would not include out-of-pocket copayments or deductibles for the patients. "Copays and deductibles are anachronisms that don't work, except to the detriment to people in poverty," he explained. He believes that the taxes necessary to support the single-payer system would be less than the nation's overall health bill under the current system.
"We pay for health care in three ways," he said. "First, through taxes that pay for Medicare, Medicaid, the Veterans Administration hospitals [and] the National Institutes of Health. The majority of health care costs are already born by the government, directly or indirectly, through the tax deduction for health expenses. Government now pays just over 50% of the health bill. Second, [we pay] out of pocket, through copayments, deductibles, pharmaceutical bills, which aren't covered by Medicare. Third, in lieu of wages: All of the premiums or benefits that we enjoy when we work for Corporation A or B or Small Businessman C are in lieu of wages. And when we get hit with double-digit cost increases, that's money out of our paychecks. Businesses are getting disenchanted with keeping this out of the hands of government. That formula has lost its glow, and businesses are increasingly responding in the worst possible way, by off-loading the costs to their workers, not covering families and cutting benefits."
Young recognized that there are vested interests in the current system which would resist change, and he proposes utilizing their abilities in other ways.
"It's a political question," he said. "A single-payer system translates to people losing jobs. How many insurance people--people at ends of telephone lines denying approvals, people holding up claims payments--are there? It may be as many as 200,000 to 400,000--that's just a rough guess--and that's where the savings come from, because those people will be redundant. So, we need to find new ways to use these people in a new system, perhaps training them to be counselors, guides or ombudsmen. Suppose we decide we want everyone to get immunizations, for example. And then there's the pharmaceutical thing: There's a world of education that needs to be done, moving peopleåto generic drugs, patient education and so forth. The people in the drug industry couldådo that. Even early detection of depression and mental disorders could be facilitated by training people as screeners."
Marmor is less sanguine about the prospects for change, and much less enthusiastic about relying on the so-called Canadian model, where government pays for all health care services. "Perhaps one of the most serious barriers to adopting a national health system is the widespread perception that Americans have only two choices in health care," he wrote.
"This dichotomy in the American health debate is one that does not, we believe, serve reformers well. It leaves the mistaken impression that the Canadian program is the only available model of universal health coverage. It ignores the comparably successful experiences of universal health insurance in Western Europe, Japan and Australia...The exclusive focus is unfortunate, from a political perspective."
He suggested a more gradual approach to change. "One possibility could be mobilizing the states that are ready to go to universal health insurance," he said. Several states--for example, Maine, Vermont, Washington, Minnesota and Wisconsin--are already leaning toward some kind of universal care plan and could serve as laboratories for creating a model that might be transferred to the national scale. "One of the attractions of this so-called federal option is that it is not hostile to Republican ideology. It is much more likely that the Republicans in Congress would be willing to support a federal option than [for example] the expansion of Medicare downward to age 55."