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Health: a Significant Step

February 12, 1989

The National Leadership Commission on Health Care has produced a constructive plan that addresses the glaring shortcomings of the American health system with ideas for strengthening its positive attributes. It is a remarkable contribution that should give impetus to reform efforts already under way in Washington and many states.

This is not a detailed report ready for implementation, however. Its most singular and detailed recommendation, assuring universal health care, will require complex legislative ingenuity. And successful implementation of the proposals to assure universal access will depend on fleshing out the less complete work of the commission on three other critical areas: cost containment, quality assurance and malpractice reform.

But those challenges should not distract the nation from the importance of the recommendations. In outlining a guaranteed minimum health-care plan for everyone, the commission has addressed the basic issues of finance and administration. A mixture of public and private funding is proposed, with everyone at or above 150% of the poverty level required to contribute. Employer-funded insurance would continue to dominate, but there would also be a basic benefits guarantee for everyone else. The federal government would establish minimum standards, but each state would administer its own program and be free to elaborate. The state role seems sensible, perhaps the only way to fine-tune a national program in a country so large and diverse. Furthermore, there is a potential in the state authorities' payment-policy powers for effectively implementing fairer compensation for doctors and hospitals, including physician compensation reforms, and winning the most competitive prices possible from providers.

The commission has left to Congress the construction of a basic benefits package. Fortunately, there already has been substantial work in that area. Implicit in the proposal, of course, is recognition of an unfortunate American reality that is not true in most other industrialized democracies: There would be universal access, but the access would be to unequal care. Two-tier medicine, minimal and deluxe, would continue. Most Americans would continue to receive, through employer-funded health insurance, far more elaborate services than would those covered by the universal-access program recommended by the commission. But that inequity is certainly more acceptable than the present situation in which 37 million persons, including 11 million children, are without any health insurance.

One of the most difficult tasks lying ahead on the national agenda set by the commission is the implementation of a national quality-improvement initiative. The commission has proposed a special tax, in addition to payroll taxes that would fund the universal-access program, to do more extensive research on the appropriateness of particular health-care services. That would also have implications for another priority--controlling the spiraling costs of health care, which are increasing in the United States at double the rate of inflation. Another cost-containment recommendation calls for reform for malpractice, and in this, too, the commission acknowledges the need for more research and experimentation.

The recommendations have drawn criticism from some of the commission members for the risk raised by proposing universal access, and thus extending protection to 37 million persons not now covered, without a refined plan for controlling the costs of that expansion in a system already beset by rampant inflation. That risk is no doubt real, but it should be taken as a caution--not a deterrent to action--because the present situation, with one in four persons inadequately protected, violates the commitment of the nation to justice and equity.

This study was a private venture, with former Presidents Richard M. Nixon, Gerald R. Ford and Jimmy Carter serving as honorary co-chairmen. Distinguished experts have spent 2 1/2 years developing the plan. They have made an extraordinary contribution. "For the Health of a Nation" is the title of the report. That is indeed what it is all about. The report carries the thinking of the nation a significant step toward recognition that public health can be made more secure only when it assures access to high-quality care for all. The report provides the Administration of President Bush and the new Congress with the framework to get on with that unfinished business.

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