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From the Editor

Goldfield, Norbert MD

Journal of Ambulatory Care Management: January-February-March 2005 - Volume 28 - Issue 1 - p 1
From the editor

This issue continues our exploration of the ambulatory care implications for society and health that Dr Celia Larson began in the previous issue. In addition, we extend our examination of society and health to an international perspective, with a particular focus on the Middle East and specifically the Arab–Israeli conflict. Typically we hear in the media about the direct physical impact of the ongoing conflict. In this set of companion articles, both the Israeli and Palestinian contributors focus on the mental health ramifications and a review of the research literature documenting the mental health impact of the ongoing conflict on their respective populations. The “Physicians for Human Rights” regular column focuses on an effort on the part of Israeli and Palestinian physicians to continue ongoing dialogues in health in an effort to improve the health status of both populations.

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The Election, Universal Coverage, and Healthcare Trends

Key words:healthcare delivery, politics, uninsured

The November election results provide a clear road map for the future of healthcare delivery in the United States.

  • The number of uninsured and, just as important, underinsured will continue to rise.
  • Employer-based coverage will continue to fray.
  • In attempting to address the rising numbers of uninsured, George Bush has promised us, among other “market-driven or individual-focused solutions,” Health Savings Accounts, a high-deductible catastrophic insurance policy.
  • The changed makeup in Congress will lead to a Medicaid block grant to the states, leading to decreased Medicaid benefits for most states, increased eligibility barriers, or both.
  • The business objective of both insurance comp-break anies and for-profit HMOs will be neither mana-break ged care nor managed risk but rather “managed” actuarial prediction of the insurance premium.
  • Pay-for-performance, a current buzzword, will have minimal impact on overall spending trends (thus leading to greater numbers of uninsured) while providing somewhat better care for the decreasing numbers of insured Americans.
  • A significant healthcare benefit, abortion services, needed for many women, particularly for poor women, will not be covered during this second Bush administration.

Those who are concerned about such trends and are advocates of universal coverage have to consider new approaches to this issue, including the following:

  • In an effort to reach across the current divide, advocates of universal coverage need to develop new constituencies and new approaches to old constituencies such as health professional groups, unions, and consumer groups, including religious groups, all of whom could be supportive of universal coverage if they also understood the potential for fundamental healthcare system change.
  • We need to stop thinking of new ways to spend money without concomitant major changes in healthcare delivery, resulting in control of healthcare costs. Doing the latter effectively will inevitably and paradoxically result in higher quality and simultaneously decrease the number uninsured.
  • Encourage devolving “fair” (not block grants) responsibility to the states, allowing them to experiment with means of controlling healthcare costs while increasing coverage.
  • Changes in healthcare delivery resulting in cost control and increased coverage include the following:
    • True pay for performance such as not paying extra for hospital complications. Current approaches barely touch the surface.
    • “Engaging” consumers in all aspects of healthcare that will not negatively affect (eg, large deductibles/co-pays) their health. Only engaged consumers can eventually be supportive of increasing coverage for the uninsured/underinsured.
    • A commitment to assess the cost-effectiveness of new technologies (including pharmaceuticals). In lieu of cost controls on pharmaceuticals we can perform cost-effectiveness evaluations, thus encouraging both the private and public sector to pay appropriately.
    • There will continue to be a split between those advocating universal coverage via a single-payer approach and those who wish to craft a uniquely American solution(s). For the foreseeable future (ie, the next generation), single payer is unattainable within an American context.
© 2005 Lippincott Williams & Wilkins, Inc.