With growing concern for the steeply rising cost of health care, coupled with the possibility of a new outlook on health issues from the reconfigured 110th Congress, opportunity exists for another serious discussion of America's health delivery system and what can be done to bring about needed improvements.

The perennial vexing issues in health policy-cost, access and quality-have suffered by neglect over the past several years. America still has an enormous uninsured or underinsured population, a core concern that is particularly embarrassing given the country's substantial affluence and resources. America spends about $6,100 per capita on health, more than any other industrialized country and almost twice that of second-place Canada. Yet our health indexes such as life expectancy and infant mortality lag behind countries that spend far less than we do on health.¹

Another issue is equityhealth disparities remain across a wide swath of the population, and compelling evidence indicates that race and ethnicity correlate with persistent and often increasing health problems. Demographic changes anticipated over the next decade magnify the importance of addressing disparities in health status.

The Cost of Reform

The U.S. health system is unique (not necessarily in a positive sense) in that it has a number of characteristics that are unlike those of most developed countries. The U.S. system is an admixture of public and private entities and is highly entrepreneurial, focused on acute care, enamored with high technology and distinctly decentralized. Its financing system is a complex public-private labyrinth, which spurs criticism that it is riddled with administrative excess and inefficiencies.² This is a point that makes a single-payer system an attractive one.

It is well known that the amount of waste and duplication adds to the cost of care and makes it difficult to obtain needed insurance coverage. As health insurance is the literal entry key to access the health system, the absence of insurance represents a major barrier for the average citizen to obtain care.

Certain basic principals are desirable if not essential: Health care coverage should be available to all citizens; coverage should be affordable and provide a sufficient package of benefits; and medical necessity determinations under the benefit package should reflect accepted standards of medical practice supported by outcomes-based evidence. One would hope that these principals would be the bedrock of reform. The obvious difficulty is, of course, cost: Who will pay for all of this?

It is hard to imagine a substantive reformation of the health system-for example, some form of universal health insurance coverage-without incurring a large public expense. In addition to Congress's traditional reluctance to increase taxes to finance such a plan, an unfortunate reality is that the cost of the war in Iraq also could preclude any meaningful discussion of health system reform.

Without a strong public mandate, the leadership and members of the newly elected Democratic Congress are unlikely to seek to raise taxes to fund health coverage lest they confirm the accusations of their opponents as the party of the "tax and spend" liberals.

A Single-Payer System

Many advocates of health system reform, including many of our PA colleagues, speak of a single-payer approach as key to health system reform. Commonly, this notion connotes a single entity, most likely a public agency, to insure all citizens and to pay all providers, hospitals and related entities.

One interesting suggestion is to expand Medicare to encompass all of the population. Using a voluntary, pay-your-own-way structure, persons would purchase insurance from Medicare by paying a premium that would cover the expected costs of their health care. As in the private sector, the premium would increase with age. Premiums would be cheaper than private insurance, since Medicare has much lower administrative costs: about 2%, as opposed to 15% to 20% for the private insurance sector.³

Medicare also would be in a position to use its bargaining power to hold down costs, especially with the pharmaceutical companies. This is a change that should be considered anyway to improve the benefit package for Medicare Part D, the flawed prescription drug plan.

Why Should PAs Care?

As a growing segment of the health care professions, PAs have a stake in the vitality and success of the health system. PAs as citizens also have reason to support a very logical position: The nation's health system should be improved to provide the care that we deserve for our tax dollars. Part of the tradition of the PA profession is that we serve in the best interests of our patients. Advocating for a more efficient and equitable health system for the country, a needed change that would benefit all, seems like a no-brainer for all members of our profession. q

James F. Cawley is director of the PA/MPH program and professor and vice chair of the Department of Prevention and Community Health, School of Public Health and Health Services at The George Washington University in Washington. He also is professor of health care sciences at the university's School of Medicine and Health Science.

References

1. Bernasek A. Health care problem? Check the American psyche. New York Times. December 31, 2006; sect B3.

2. Characteristics of the U.S. health care system. In: Shi L, Singh D. Essentials of the U.S. Health Care System. Sudbury, Mass: Jones and Bartlett; 2005:8.

3. Weisbrot M. The Medicare model for health reform. Sacramento Bee. December 19, 2006.