Mayo Clinic aims for health system reform

Rochester, Minn. -- Policy leaders gathered at a Mayo Clinic health system reform meeting agreed on one thing -- the nation needs universal health care coverage. But they disagreed fundamentally on how to accomplish this goal, with some arguing that states should take the lead and others advocating a fresh national approach.

The Mayo Clinic held the three-day symposium late last month as a first step in a national, long-term effort to develop consensus on the issue. The event drew more than 250 experts in health care, business, government and academia to Rochester, Minn.

An electronic poll of attendees found that 74% agreed or strongly agreed there is a moral imperative for all U.S. citizens to have health insurance. An estimated 46 million Americans are now uninsured.

Sitting on a panel of five health policy experts, Stuart Butler, PhD, vice president of domestic and economic policy studies at the Heritage Foundation, promoted the state-based approach to health system reform. The foundation is a conservative think tank in Washington, D.C.

"The only way we can do it is incrementally, and we must do it through the states," Dr. Butler argued. Americans "are highly resistant to big changes, and doing it through the states is the only way we'll see any movement," he added.

David Kendall, senior health policy fellow at the Progressive Policy Institute in Washington, D.C., agreed that policy-makers should "look to the states" to make progress toward universal health care coverage. PPI is a center-left think tank.

Kendall pointed to Massachusetts as an example of successful, state-based reform aimed at universal coverage. Gov. Mitt Romney, a Republican, signed legislation in April that requires all residents to purchase health insurance by July 1, 2007. The law also creates state-subsidized health insurance for those with incomes up to 300% of the federal poverty level, which is $29,400 for an individual and $60,000 for a family of four. "Massachusetts got it right," Kendall said.

The American Medical Association has also praised the new Massachusetts law. "The AMA is very supportive of encouraging states to be incubators for reform," a spokeswoman said.

A national vision

Victor Fuchs, PhD, a professor emeritus of economics and health research and policy at Stanford (Calif.) University, took issue with using incremental, state-based approaches to achieve universal coverage. The experience of the last 40 years is that incremental change makes the system worse, not better, Dr. Fuchs said.

"When Medicare and Medicaid were implemented in 1965, people who had advocated for universal coverage said, 'Don't worry about it. This is just a first step, and soon we'll have universal coverage.' Well, it's 40 years later and we still don't have it."

States can try only to patch the existing system of employment-based insurance and Medicaid, Dr. Fuchs said. "And since those two approaches to insurance are very deeply and irreparably flawed, I can't see how you get to a satisfactory system by trying to put Band-Aids on a very badly flawed system."

Dr. Fuchs called instead for a national overhaul of the health insurance system. He and fellow panelist Ezekiel Emanuel, MD, an oncologist who chairs the Clinical Bioethics Dept. at the National Institutes of Health, proposed that the United States establish a universal health care voucher system that provides every household in America a taxpayer-funded, risk-adjusted voucher to enroll in a private health plan of their choice. Under their proposal, the voucher would guarantee everyone enrollment in a basic health plan that covers doctor visits, hospitalizations, pharmaceuticals and catastrophic care. Families and individuals could choose to purchase additional coverage with their own money.

An independent federal board, modeled on the Federal Reserve Board, would administer the new voucher system. The board's functions would include contracting with and reimbursing health plans and defining the basic benefit package. Like the Federal Reserve, the new health board would regularly report to Congress, but its members would have long-term appointments to be insulated from political pressure.

Dr. Emanuel predicted that large employers and state governments, buckling under the high cost of health care, would support vouchers.

"Business is not interested in single-payer or employer mandates, so you need to give them an alternative they can support." As for the states, he said, "Medicaid is killing them."

The AMA has its own reform proposal. In the short term, the Association is advocating incremental measures to expand coverage for children and lower-income families and individuals. In the long term, the AMA is pressing for a consumer-driven, market-based plan to expand coverage through tax credits and insurance market reforms.

At press time, the AMA was set to consider expanding this policy to make buying insurance a personal responsibility.

The challenge, Dr. Fuchs said, is convincing federal lawmakers to take up any kind of national health system reform. He predicted that only a large-scale crisis, such as a major war or depression, would drive Congress to attempt sweeping changes.

Symposium co-chair Hugh Smith, MD, former chair of the Mayo Clinic Rochester Board of Governors, said Mayo's goals for the symposium were to highlight the urgent problems facing the health care system and begin developing a new vision of health care in America. "We don't pretend to have all the bright ideas," Dr. Smith said. "But we do feel we have a responsibility to create a platform where all stakeholders have a voice."