Two nations, one debate over how to achieve reform

For the last nine months, much of the debate over health system reform in the United States reflects a simple question: What is the role of government versus the role of the private sector?

This same question was recently posed at the 142nd annual meeting of the Canadian Medical Assn. that I was honored to attend as the official representative of the American Medical Association.

This question was posed in the form of a resolution: "The CMA supports a requirement that any medical practitioner providing a medically necessary service to an eligible Canadian in a private health care setting not bill or earn more for that service than they would in the public health system."

Driving the resolution was the social contract that the medical profession forged in Canada to provide medical care for its citizens through its own Medicare system, which set up a recession-protected revenue stream to pay for medical care. The CMA's own blueprint for the future of Canadian health care includes the goal of patient-centered care with seamless access and without financial barriers for patients.

Those who argued in favor of the resolution said fee differentials between the public and private system don't constitute patient-centered care but physician-centered care. They noted that fee differentials are divisive, because they benefit nonprimary care specialists and create perverse incentives for patients and physicians.

For patients, it gives incentives to jump ahead of the waiting lines. For physicians, it gives incentives to charge increased billing fees to enhance one's income. (In Canada, physicians have private practices but also bill the government for the professional services. About 20% to 30% of patients also have private insurance.)

Those speaking against the resolution suggested the monopoly power of the government was not friendly to physicians. They noted that because of the inability of the government to provide all services in a timely fashion, that some provincial governments -- Quebec, for example -- had expanded the number of procedures that the government would pay the private sector to provide from three to 56.

Some in the United States who oppose increased federal government involvement in health care point to the number of Canadians who have come to the U.S. to receive medical diagnostic and therapeutics as the reason why such an expansion will not be good for patients. What is not noted are the Americans who leave the United States to receive orthopedic and cardiovascular surgery in Taiwan, India and other nations by American-trained, American-board-certified physicians in Joint Commission International-accredited facilities at half the cost and with similar outcomes. The consulting firm Deloitte estimates that the number could rise to 6 million by the end of next year.

Like the AMA, the CMA has sought clues from other nations on how to change the system to strike the right balance between the government and the private sector. Those selected were Belgium, Denmark, England, France and the Netherlands. The AMA has looked at Taiwan and Australia.

While no health care system is perfect, the balance of access to care with quality and cost continues to be a common theme -- and each nation has to decide what is best for its own citizens.

After I returned from Canada, I attended meetings that my congressman held with patient advocacy groups and health professionals, including physicians. At the first meeting, we heard many personal stories of the preexisting condition exclusion problem.

One small-business owner noted that if an employee at his business received a diagnosis of heart disease or cancer, the resulting increase in premiums would force him to drop health insurance for everyone in the business. Scenarios such as this aren't going to improve either the health of Americans or the health of our economy.

In the United States, we have access to the latest cutting-edge technology, wielded by physicians who put in long years of training and education, and long hours of dedicated work for their patients. The reality of the lack of access to care for the uninsured and the underinsured is among the biggest sticking points. The AMA vision for health system reform solves that with the mandate that all individuals should have health insurance, and if they cannot afford it, receive advanceable tax subsidies to purchase their own policies.

By the time you read this column, Congress will have returned from their August recess and will be engaged in the discussion of the next steps in health system reform. The AMA has set up a Web site to provide you the latest information and how to get involved (link).

For our part, we're keeping up the pressure for reform. Last week we sent an open letter to the president and Congress reminding them of the need for reform -- and what reform needs to do.

Reforms need to:

• Provide health insurance coverage for all Americans.
• Enact insurance market reforms that expand choice of affordable coverage and eliminate denials for preexisting conditions.
• Assure that health care decisions are made by patients and their physicians, not by insurance companies or government officials.
• Provide investments and incentives for quality improvement, prevention and wellness initiatives.
• Repeal the Medicare physician payment formula that will trigger steep cuts and threaten seniors' access to care.
• Implement medical liability reforms to reduce the cost of defensive medicine.
• Streamline and standardize insurance claims processing requirements to eliminate unnecessary costs and administrative burdens.

The challenges in our health care system are many and complex. But enactment of these policies will create the foundation for a stronger, better performing health care system in this country, improve access to affordable, high-quality care and reduce unnecessary costs.

Further, those who are currently insured, including patients on Medicare, and those who are uninsured all will benefit from greater security and stability.

Some of this may seem scary, but as Heraclitus noted in 400 B.C.E., the only thing constant is change. Sir William Osler put it a different way a century ago, "If you want a profession in which everything is certain, you had better give up medicine."

Our AMA will be fighting for our profession and ensuring that all of the medical decisions will continue to be between your patient and yourself, based on the evidence of what is best for your patient. That is the core of what we do as physicians and the reason why the AMA helps doctors help patients.