Rekindling Reform: Principles and Goals
Members of the Rekindling Reform Planning Committee collaborated over a period of several months to develop a set of principles and goals to help guide and define the group s efforts for comprehensive health care reform in the United States. The next step will be to circulate the document below to the sponsoring organizations for their suggestions, amendments, and approval. This document is, then, a work-in-progress, subject to revision as the process of discussion and review continues. These principles provide a sense of the lessons members of the Rekindling Reform Planning Committee have learned from their study of other countries universal healthcare systems, and how those lessons have informed their thinking about the nature of the health care reform needed in United States.
Rekindling Reform is an initiative that grows out of the conviction of participating groups that the health system in the United States needs comprehensive reform. Every other industrialized nation covers its population for health care; in the U.S. there are 40 million people uninsured, and millions more under-insured and insecurely insured. We spend more than 14 per cent of our gross domestic product (GDP) on health care; other high-income nations cover everyone while spending only 7 to 10 percent of their GDP. If the resources our country devoted to the health care sector resulted in quality health care for all there would be little objection to spending 14 per cent of GDP. But today s allocation of one seventh of our economy to health care supports a system of health care financing and provision that is unfair, inefficient, and ineffective in insuring the nation s health.
Our Rekindling Reform initiative undertook a study of four industrialized nations with universal health care coverage: Canada, France, Germany and the United Kingdom. These countries organize their health care financing systems very differently from one another: The United Kingdom has a national health service; Canada uses fee-for-service payments to providers and annual global budgets to hospitals administered through provincial governments; Germany and France use non-profit health insurance funds and reimbursement entities, operating under government oversight and regulation, to pay the providers of health care. Despite these differences, some important commonalities were observed:
(1) Health care is regarded as a universal right, not a privilege.
Access to health care is assumed to be a right of all residents. It is not dependent on an individual choosing to participate, working for a particular employer, or paying at the time care is received. Instead, all contribute, and all can benefit.
(2) The government has a key role.
In every country we examined, a strong government presence defines universal health benefits, sets standards, and assures fairness and equity. Regardless of the specific manner in which revenues are raised or disbursed, the national government oversees the entire process, providing a powerful public mechanism for sharing risk and assuring that all residents have access to essential health care.
(3) Health care financing is part of a national social insurance program, rather than a system driven by private, for-profit insurance companies.
Each country examined uses some combination of governmental and non-profit management, with only a peripheral role for private profit-making insurance companies. Health care premiums are not calculated on the basis of actuarial risk; rather, the financing is based on the assumption that the entire population should be part of the same risk pool and contribute their share of premiums on the basis of ability to pay. Risk is shared by all rather than being avoided by companies seeking competitive advantage. Public and non-profit systems are far more cost efficient than the current U.S. health care system, as well as being vastly more humane.
(4) Reform of the health care financing system and coverage is frequently kept separate from reform of the delivery system. However, there continue to be adjustments from time to time in the provider payment systems and the organization of the delivery system.
How providers are paid is a factor in how health services are delivered, as well as in cost control. In all of the countries studied, there is continuing public discussion of issues affecting the system. In particular, the balance between primary care and inpatient services, the geographic distribution of services, the incorporation and coverage of new technology, ways to improve the quality of care, the overall level of expenditure, and other issues are always under public review.
Informed by these observations, a set of six principles for Rekindling Reform have been agreed upon that outline an equitable, humane and cost-effective health care system for the United States. These principles do not provide a detailed blueprint for changing the health care system, but they do serve as benchmarks for judging health care reform proposals.
1) Universal and equitable coverage. Everyone should have equal access to the care they need when they need it, without financial hardship.
2) Comprehensive benefits and quality health care. Everyone should receive the full range of services that is effective in preventing illness and improving health; no one should receive care that is ineffective or harmful.
3) Affordable and equitable financing. In light of the nation s other vital needs, the cost of the entire health care system should not be excessive. Costs should be controlled and affordability assured by: a) including everyone so that risk is spread over the entire population and the system is financed equitably; b) reducing paperwork and limiting structures that divert health dollars to management rather than patient care; c) emphasizing prevention and effective community-based primary care so as to reduce the need for costly acute care and emergency treatment. People with more money should pay a higher proportion of their income and/or wealth than people with less money.
4) Simplified administration and sensibly organized work. Individuals should not be burdened with administrative and logistical obstacles to the provision or receipt of care. Providers and caregivers work should be organized so that they can serve their patients to the best of their abilities under conditions that do not lead to undue job stress or burnout.
5) Accountability. The system should be organized so that individuals, providers and all those whom the system is designed to serve have input, resulting in the maximum responsiveness to the public s needs.
6) A strong public health system. The public health system should be organized to integrate the health care delivery system with community and other preventive and social services, and maintain a safe food and water supply and environment for all.
To put the above principles into practice, Rekindling Reform is working to achieve a health care system that:
(1) guarantees that every person in the United States, regardless of age, employment or health status, or ability to pay has access to health care;
(2) does not discriminate by race, gender or sexual orientation;
(3) works to eliminate disparities in the receipt of quality health care by eradicating financial barriers to care and by striving to overcome non-financial barriers such as class, ethnicity, race, language, education, gender, sexual orientation, and geography;
(4) addresses the needs of people with special health care needs and underserved populations in rural and urban areas.
(5) provides comprehensive benefits, including prescription drugs, rehabilitation, dental care, vision care, mental health care, complementary treatments, and occupational and long term care services in a site appropriate to patient needs (including home, hospice or nursing home). Benefits are sufficiently broad so that people do not have to purchase supplemental insurance to cover multiple exclusions of medically necessary care;
(6) includes parity for mental health and other services;
(7) promotes prevention, and early intervention. Health is enhanced and clinical waste is minimized through public health, self-care, prevention, strong primary care with a primary care practitioner for everyone, and avoidance of unnecessary procedures;
(8) ensures continuity of coverage and continuity of care;
(9) maximizes consumer choice of health care providers and practitioners;
(10) promotes quality and better health outcomes;
(11) ensures that private coverage does not duplicate the comprehensive benefit package.
(12) is affordable to individuals and families, businesses and taxpayers; removes financial barriers to needed care;
(13) is progressively financed, with everyone contributing according to their income and/or wealth;
(14) is as cost efficient as possible, spending the greatest possible proportion of total funds on necessary and efficient health services and a minimum proportion on the administration of finances.
(15) is easy for patients and providers to use and reduces paperwork;
(16) ensures adequate numbers of qualified health care caregivers, practitioners, and providers, with appropriate distribution of practitioners between primary and specialty care, to guarantee timely access to quality care. Supports education and training programs for all health workers;
(17) structures the health care work force so as to avoid excessive fatigue and the consequent burnout and medical errors;
(18) promotes affirmative action programs in the training, employment, and promotion of health workers to help the system to address the needs of underserved populations;
(19) assures that practitioners and other health workers are paid fairly and equitably, taking into account their local circumstances, with timely payments to guarantee access to care;
(20) fosters a strong network of non-profit health care facilities, including safety net providers;
(21) educates consumers about their health rights and responsibilities.
(22) provides for ongoing evaluation and planning, with consumer, practitioner, caregiver and provider participation, to improve the delivery of health services;
(23) requires that decisions about all policy and regulatory matters, including the parameters of medically necessary care to be covered, are open and are publicly debated;
(24) ensures that health care is organized and administered through publicly accountable mechanisms to result in maximum responsiveness to public needs. Accountability is public for costs, quality and value of the services of practitioners, suppliers and administrators.