One hundred years after Theodore Roosevelt proposed studying the European model of nationalized health insurance, America has finally listened. Instead of a direct route to the Bismarck-style system in which the population is divided among multiple private payers, Americans opted for a voluntary employer-based system.
It took nearly fifty years after Roosevelt for the country to provide elderly retirees and extremely poor Americans coverage with Medicare and Medicaid. All the while, federal employees, the military, and veterans were placed into other risk pools. Still, most Americans either obtained their health insurance through the benevolence of "the progressive employer" or went without.
The uninsured were left at the mercy of a for-profit insurance industry designed to do one thing: deliver profits for shareholders. That is the system we have inherited, largely unchanged, until recently.
The Affordable Care Act, recently affirmed by the Supreme Court, will require that almost all Americans obtain health insurance. But it falls far short of ensuring universal health care in the United States. While the passage and implementation of the Affordable Care Act is a step in the right direction, the rational and universal health care system envisioned by Roosevelt requires several additional reforms.
•Demanding quality. Patients and payers must demand the highest quality and the best evidence-based medical care from hospitals and physicians. While this proposition likely includes pay-for-performance, quality initiatives should focus on validity and provider buy-in in the near term before placing significant financial risk on physicians and facilities.
•Demanding time. Today's frenetic pace of 15-minute office visits and office hours revolving around the physician's schedule does little to benefit the patient. Instead, it likely leads to over-testing, unscheduled visits to urgent care centers and emergency rooms, and frustrated patients. One of the greatest remedies a physician can offer his or her patient is time.
Our health care system must incentivize time with doctors, specifically, time that is convenient to patients. Insurers need to start paying physicians more money whenever they see patients after 5p.m., on the weekends, or in their homes.
•Exchanging information. One of the most unnerving aspects of working in the health care system is that information is spread across multiple platforms and is unnecessarily difficult to access for health care providers. This delays care, results in duplication, and is dangerous to patients when providers must practice without sufficient information. Patients and providers alike should demand a repository of medical information that is easily accessible, secure and constantly available to facilitate the practice of medicine while minimizing duplication.
•Community level controls. A one-size-fits-all national approach to health reform will not adequately benefit patients in all corners of this vast and diverse country. Communities, whether at the state, county, or municipal level, should be the locus for much of reform's outreach efforts. At a minimum, each state should control and narrowly tailor health care decisions to its population.
•A universal risk pool. A bold step toward universal health care requires the consolidation of risk pools. Health insurance, like any other type of insurance, works best whenever the risk is spread across a broad population. The presence of more than six major federal health programs, countless state and local health programs, and dozens of private health insurers partitions the public into smaller and smaller subsets, which makes adequate spreading of risk unnecessarily difficult. Ultimately, risk should be spread across broad communities, such as entire states, as is happening in Vermont.
•Eliminating the profit motive. Lastly, the profit motive must be removed from health care. While physicians and nurses should receive fair compensation for service to their patients, institutions such as hospitals and insurers should never profit from of the misfortunes of another human being. The non-profit model worked well in the early days of private health insurance; the discriminatory practices of modern day insurers only surfaced upon the arrival of their for-profit cohorts.
Several Western capitalist societies already possess a private, non-for-profit health insurance sector. We would be wise to look to these nations, Switzerland and Germany especially, as a roadmap to universal health care in the United States.