American Journal of Psychotherapy

VOLUME XXXII, NUMBER 4 OCTOBER

1978

EDITORIAL National Health Insurance Program Update—The Normative Planning

Need for

D u r i n g t h e past few weeks, a t t e m p t s t o pass a N a t i o n a l H e a l t h I n s u r a n c e P l a n w e r e s i d e t r a c k e d because t h e p r o p o s a l was c o n s i d e r e d t o be t o o e x p e n s i v e . T h e m a i n s p o n s o r o f t h e p a r t i c u l a r b i l l c l a i m e d t h a t " t h e n a t i o n c o u l d n o t a f f o r d n o t t o pass his b i l l . " W e believe t h a t t h e p a r t i c u l a r p r o p o s a l r i g h t l y was set aside, n o t because o f its t h e o r e t i c p u r pose ( w h o w o u l d q u a r r e l w i t h t h e a i m t o s u p p l y a d e q u a t e h e a l t h c a r e ) , n o t o n l y because o f its cost, b u t because o f its d e s i g n . L i k e t h e designs o f all t h e n a t i o n a l h e a l t h i n s u r a n c e plans t h a t are b e f o r e t h e C o n g r e s s i t is naive a n d inadequate. A p p r o x i m a t e l y t w o years ago t h e e d i t o r was i n v i t e d b y t h e U n i t e d States G e n e r a l A c c o u n t i n g O f f i c e t o serve as a m e m b e r o f a T a s k F o r c e O n N a t i o n a l H e a l t h I n s u r a n c e w h i c h was set u p to a i d t h e G e n e r a l A c counting Office. A s w i t h so m a n y g o v e r n m e n t p r o j e c t s t h e p r o g r a m was s t o p p e d i n m i d s t r e a m . I n d e e d , this is w h e r e t h e e n t i r e N a t i o n a l H e a l t h I n s u r a n c e p r o g r a m a p p e a r s t o be. H e a l t h scientists, i n g e n e r a l , are p o l i t i c a l l y d i s i n t e r e s t e d , a n d i f i t is possible, t h e y are e v e n less i n t e r e s t e d a n d k n o w l e d g e a b l e i n f u t u r e s p l a n n i n g . T h e t r a g i c r e s u l t is t h a t t h e f u t u r e o f the h e a l t h sciences is bei n g d e c i d e d , i n t h e m a i n , by p o l i t i c i a n s , b u r e a u c r a t s , a n d special i n t e r e s t g r o u p s . F o r those w h o have l i t t l e awareness o f t h e g e n e r a l N H I p r o posals t h a t h a v e b e e n o f f e r e d , we suggest t h a t t h e y c o n s u l t a g o v e r n m e n t p u b l i c a t i o n e n t i t l e d " N a t i o n a l H e a l t h I n s u r a n c e P r o p o s a l s " c o m p i l e d by Saul W a l d m a n , U.S. Social S e c u r i t y A d m i n i s t r a t i o n , O f f i c e o f R e s e a r c h a n d Statistics, 1976. T h e r e are t h r e e g e n e r a l categories o f p l a n s t h a t h a v e b e e n p r o p o s e d t o t h e C o n g r e s s . T h e f o l l o w i n g are some o f t h e salient f e a t u r e s o f each: Health

Security

Act.

T h i s is a p r o g r a m that w o u l d be a d m i n i s t e r e d by the

F e d e r a l G o v e r n m e n t a n d financed by special taxes o n e a r n e d a n d u n e a r n e d i n c o m e a n d by F e d e r a l g e n e r a l r e v e n u e s .

I t closely resembles the

noto-

riously e x p e n s i v e a n d inefficient B r i t i s h N a t i o n a l H e a l t h I n s u r a n c e P r o g r a m that has c o n t r i b u t e d to a n e a r state o f b a n k r u p t c y in the U n i t e d K i n g d o m . Under

this p r o g r a m ,

all U . S . residents w o u l d

w i t h o u t cost s h a r i n g by any patient.

be i m m e d i a t e l y

covered

A d m i n i s t r a t i o n a n d c o n t r o l w o u l d be

u n d e r the auspices o f a special b o a r d i n the D e p a r t m e n t o f H e a l t h , E d u c a tion a n d W e l f a r e with r e g i o n a l local offices setting u p quality a n d cost c o n -

493

trols.

M e d i c a r e w o u l d be a b o l i s h e d w h i l e M e d i c a i d w o u l d not pay

for

c o v e r e d services.

Comprehensive Health Insurance

Plan.

T h i s w o u l d be a two-part p r o g r a m

i n c l u d i n g : (1) a p l a n r e q u i r i n g e m p l o y e r s to offer private h e a l t h i n s u r a n c e for e m p l o y e e s ; (2) a p l a n m a k i n g private i n s u r a n c e available for the n o n e m p l o y e d a n d s e l f - e m p l o y e d w i t h F e d e r a l subsidies o f the p r e m i u m s p r o v i d e d t h r o u g h tax credits or subsidy certificates. general, would

A s to c o v e r a g e , the benefits, i n

be s i m i l a r to those c o v e r e d by the H e a l t h S e c u r i t y A c t

d e s c r i b e d above.

I n s u r a n c e w o u l d be i s s u e d t h r o u g h private c a r r i e r s o r self-

i n s u r e d a r r a n g e m e n t s , s u p e r v i s e d a n d a d m i n i s t e r e d by the States u n d e r F e d e r a l regulations or by the F e d e r a l G o v e r n m e n t directly. be

continued

while Medicaid

would

be

Medicare would

l i m i t e d to specific

noncovered

services.

Comprehensive Health Care Insurance Act.

T h i s w o u l d be a t h r e e - p a r t p r o g r a m

i n c l u d i n g : (1) a p l a n r e q u i r i n g e m p l o y e r s to p r o v i d e private h e a l t h i n s u r a n c e for e m p l o y e e s ; (2) a n assisted p l a n for the l o w - i n c o m e a n d h i g h - m e d i c a l - r i s k p o p u l a t i o n s ; (3) a n i m p r o v e d F e d e r a l p r o g r a m for the a g e d . system all p e r s o n s w o u l d be c o v e r e d .

U n d e r this

I n s u r a n c e w o u l d be p r o v i d e d t h r o u g h

private c a r r i e r s s u p e r v i s e d by the States u n d e r r e g u l a t i o n s i s s u e d by a n e w Federal board. from carriers.

B o t h e m p l o y e r s a n d families w o u l d p u r c h a s e i n s u r a n c e M e d i c a r e w o u l d c o n t i n u e while M e d i c a i d w o u l d not pay for

c o v e r e d services.

O u r d e v e l o p i n g p o s t i n d u s t r i a l society d e s p e r a t e l y needs a r a d i c a l l y n e w a n d d i f f e r e n t f o r m a t t h a t w o u l d reflect t h e d e m a n d s r e s u l t i n g f r o m t h e i n t e r r e l a t i o n s h i p s o f c u l t u r a l , e c o n o m i c , p o l i t i c a l , d e m o g r a p h i c , ecol o g i c , a n d t e c h n o l o g i c forces t h a t w i l l d e t e r m i n e t h e stresses, n e e d s , a n d goals o f c o m i n g g e n e r a t i o n s . T h e p r o g r a m s d e s c r i b e d above are i n a d e q u a t e t o m e e t t h i s c h a l l e n g e b o t h i n t h e o r y a n d d e s i g n . T h e y are e x a m ples o f e x p o n e n t i a l p l a n n i n g (based o n m e t h o d o l o g i c e x t r a p o l a t i o n o f t h e past a n d p r e s e n t d e v e l o p m e n t s i n t o t h e f u t u r e a n d as s u c h , r e p r e s e n t m o r e a n d m o r e o f t h e same). T h e e d i t o r has p r o p o s e d a n i n t e g r a t e d N a t i o n a l H e a l t h I n s u r a n c e P l a n t h a t is n o r m a t i v e i n c h a r a c t e r (based o n t h e assessment o f f u t u r e needs, stresses, goals t h a t t h e n w o r k s b a c k w a r d t o t h e p r e s e n t ) . This p r o p o s a l has b e e n s p e l l e d o u t i n a series o f e d i t o r i a l s especially those entitled " T h e Day o f R e c k o n i n g — T h e National H e a l t h Insurance P r o g r a m , " i n t h e J u l y , 1976 a n d O c t o b e r , 1976 issues o f t h e American Journal of Psychotherapy. T h e f o l l o w i n g is a s u m m a r y o f some o f t h e i m p o r t a n t p o i n t s o f this p r o g r a m : Stage I (five t o t e n years). R e v i e w , c o n s o l i d a t i o n , a n d / o r e l i m i n a t i o n o f o u t d a t e d a n d u n d e r u t i l i z e d facilities; m e r g e r o f g o v e r n m e n t hospitals w i t h t h e v o l u n t a r y h o s p i t a l system. F r o m a n a d m i n i s t r a t i v e s t a n d p o i n t , t h e p l a n w o u l d be r e m o v e d f r o m t h e aegis o f H E W . A n e w d e p a r t m e n t w o u l d be established w h i c h w o u l d be o p t i m a l l y a u t o m a t e d . Following t h e c o m p l e t i o n o f t h e first stage t h e b u r e a u c r a c y w o u l d be p h a s e d o u t . A n e w table o f o r g a n i z a t i o n f o r each n e w phase w o u l d be e s t a b l i s h e d t o

prevent development o f an entrenched, self-defeating bureaucracy. T h e i n s u r i n g a n d p a y m e n t o f h e a l t h c l a i m s w o u l d be t h r o u g h p r i v a t e c a r r i e r s . T h e p l a n w o u l d be financed t h r o u g h Social S e c u r i t y o r t h e i n come tax s t r u c t u r e d e p e n d i n g u p o n certain factors. T h e public s h o u l d be u n d e r n o i l l u s i o n s t h a t t h e y are " g e t t i n g s o m e t h i n g f o r n o t h i n g . " Research a n d d e v e l o p m e n t d u r i n g Stage 1 w o u l d r e q u i r e l a r g e expenditure o f funds and a cooperation between the private and public sectors i n a m a n n e r r e m i n i s c e n t o f N A S A . Special a t t e n t i o n w o u l d be d e v o t e d t o (a) t h e d e v e l o p m e n t o f a n e w i n t e r l o c k i n g c l i n i c a n d h o s p i t a l system; (b) t h e d e v e l o p m e n t o f a H a b i t a t - d e s i g n o f a r c h i t e c t u r e f o r hospitals a n d c l i n i c s ; (c) t h e d e v e l o p m e n t o f a u t o m a t e d a n d e v e n t u a l l y c y b e r n a t e d d i a g n o s t i c systems; (d) t h e d e s i g n a n d i m p l e m e n t a t i o n o f "a h e a l t h science m e m o r y b a n k s y s t e m ; " (e) t h e p l a n n i n g a n d d e v e l o p m e n t o f i n s t i t u t e s t o t r a i n a n e w t y p e o f h e a l t h science p e r s o n n e l ( H e a l t h Academicians and H e a l t h Technical Experts). Stage 2. I m p l e m e n t a t i o n o f t h e e n t i r e l y n e w h e a l t h science d e l i v e r y system, i n c l u d i n g h e a l t h science d i a g n o s t i c u n i t s , ( i n i t i a l l y a u t o m a t e d b u t eventually cybernated) w h i c h w o u l d take very detailed histories by c o m putest language, p e r f o r m definitive physical examinations, b r o a d s p e c t r u m l a b o r a t o r y r e c o r d i n g s s u c h as b i o - c h e m i c a l p r o c e d u r e s , p o l y graphic a n d radioactive tracings, X - r a y evaluations, a n d a variety o f c o m p u t e r i z e d t o m o g r a m s . A l l t h e m a t e r i a l w o u l d be " e v a l u a t e d " b y a p p r o p r i a t e l y p r o g r a m m e d c o m p u t e r s f o r d i f f e r e n t i a l diagnoses a n d t h e r a p e u t i c r e c o m m e n d a t i o n s . A " h e a l t h science m e m o r y b a n k s y s t e m " w o u l d be i n o p e r a t i o n w h e r e b y a l l d a t a p e r t a i n i n g t o a p a t i e n t ' s h e a l t h w o u l d be s t o r e d . T h i s m a t e r i a l w o u l d be s c a n n e d b y c o m p u t e r s w h i l e " i n s t o r a g e . " I f s u b p h e n o t y p i c suggestions o f a n a b n o r m a l i t y w e r e d i s c o v e r e d by t h e c o m p u t e r , t h e p a t i e n t w o u l d be c a l l e d u p e a r l y f o r a detailed evaluation. T h e new interlocking, hierarchically o r d e r e d c l i n i c a l a n d h o s p i t a l system c o u l d f u n c t i o n o n a 2 4 - h o u r basis. This system w o u l d s h a r p l y l i m i t costs a n d g u a r a n t e e o p t i m a l efficiency a n d m i n i m a l d u p l i c a t i o n . T h e system w o u l d h a v e t h r e e o r g a n i z a t i o n a l levels; (a) d i s t r i c t g e n e r a l h e a l t h c l i n i c s ; (b) r e g i o n a l specialty c e n t e r s ; (c) zone specialty h o s p i t a l s . T h e p r o g r a m w o u l d o f f e r t o t a l m e d i c a l care f o r e v e r y o n e a n d w o u l d be financed t h r o u g h i n c o m e t a x levies a n d t h e Social S e c u r i t y system. T h e p r o g r a m s h o u l d n o t be financed t h r o u g h Federal general revenues. T h e bureaucracy that administers the p r o g r a m s h o u l d be p h a s e d o u t e v e r y five years t o be r e p l a c e d b y a n e w table o f o r g a n i z a t i o n . I t is o n l y t h r o u g h a u t o m a t i o n a n d e v e n t u a l c y b e r n a t i o n t h a t a n econ o m i c a l l y realistic N a t i o n a l H e a l t h I n s u r a n c e P r o g r a m w i l l be feasible. M e d i c i n e as w e have k n o w n i t w i l l d i s a p p e a r . H o p e f u l l y , t h e h u m a n i s m t h a t c h a r a c t e r i z e d t h e 2 5 0 0 years o f m e d i c i n e w o u l d be i n c o r p o r a t e d i n t o t h e n e w system. STANLEY LESSE,

M.D.