Douglas Benn, DDS, PhD, Professor of Radiology and Director, Oral Diagnostic Systems, Department of Oral Surgery and Diagnostic Sciences, University of Florida, Gainesville, FL - Views expressed in the paper represent the author's, not the University of Florida.
352-392-5210, [email protected]

This report is divided into three sections: 1) analysis of current health system problems, 2) suggestions for a new system, and 3) how this relates to the health Magna Carta.

The current problems are due to a system designed to treat acute episodes of disease rather than to prevent or delay the onset of chronic diseases, which consume 80% of health expenditures. Health care is designed to provide disease cures isolated from the non-medical causes of disease, which are primarily poverty due to lack of education and life skills. Although many people believe that fee-for-service, malpractice litigation, high hospital and drug charges, insurance company profits, and expensive administration overheads are the causes of the US health systems failure to provide cost-effective equitably distributed care, they are exacerbating factors but not the cause. The principal cause is the failure to have an effective disease prevention, health promotion system designed to operate at the community level with the patient being trained to be their own self-care expert. By developing a self-care approach to disease prevention management, it has been shown that health costs decrease from reduced patient demand without sacrificing quality of health care.

The proposed new system has two separate parts. The first is designed to raise single parent families out of poverty into jobs paying at least 1.5 times the federal poverty level with the potential for increased earnings. One suggested model is based on combining a vocational training with health education in a "village" attached to a nursing home. The villages are run by not-for-profit companies, with mothers achieving a Licensed Practical Nurse qualification after two years. The following three years they work in the nursing home to pay for the first two years of food, accommodation, clothing, day care and training. Part of the funding is from existing federal or state grants, such as training, and part from the company. If only 500, out of a total of 17,000 nursing homes, establish villages they could train 50,000 single parents over five years with 150,000 children in a healthy environment.

The second proposal is to develop a comprehensive national health care plan to cover the current Medicaid, Medicare, and uninsured populations, using existing public health expenditure levels. By combining capitation plans with community based disease prevention, patient self care leading to reduced care from demand management, it should be possible to cover 50% of the population. Current privately insured people would have the choice of purchasing cover with the national plan. In this way, the cheaper, better national plan would compete in the private sector but employers and individuals would retain the choice of public or private insurance.

Estimates of cost are provided for developing these concepts further. To test the vocational villages in five states over five years requires $14,000,000. To develop a detailed plan for comprehensive coverage for 50% of the population, within existing public expenditure levels, will require $1,000,000.

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Medicare for All

Frank Yuse, M.Ed.Adm (1927-2005)
Spokane, WA.

Last year I decided that a full reform of the U.S. heath care system was not wise or doable. After the defeat of Oregon's Proposition 23, I realized that reform must be limited, as the current Medicare for senior citizens is limited. My reading of the American Journal of Public Health (AJPH), January, 2003, issue confirmed my conviction that it is more realistic to expand a current system than to attempt a drastic overhaul. Hence, "Medicare for All (MFA)."

This plan starts with the current Medicare model, covering 80% of basic health care costs, and expands it to insure all residents of the U.S. MFA will begin with the lists of benefits outlined in Medicare literature, adjusted to all ages, and it will include prescription drugs. Articles in the AJPH highlight lessons the U.S. can learn from universal health care in Europe and Canada. MFA has incorporated the good points, and has tried to avoid the pitfalls.

This proposal will be a mix of public (80%) and private (20%) insurance coverage, or out-of-pocket. It will be portable and therefore not dependent on employers' involvement. Assessment for MFA will be on individuals' gross incomes. Waivers for this contribution and/or co-payments will be available. As with the income tax, the assessment will be on a graduated scale. The rules for MFA will be set by the Federal Government and monitored using total quality management standards. Premiums will be paid into a trust fund which will also disperse funds to state agencies for claims payment. Medicine will be evidence-based using community ratings. This plan is not intended to be comprehensive, merely a social safety net, leaving powerful private insurance companies free to compete for the remaining costs.

MFA is a wellness approach, not just a sickness cure. It will emphasize preventive care since healthy people contribute to society and hold down health care costs. To bring this plan to reality implies a popular movement to elect friendly representatives who promise to vote for enabling legislation. It asks for dedicated leaders who will work for this pragmatic, realistic solution to our health care crisis. In light of recent political defeats, this seems to be the best compromise, one which has a chance to succeed. It will win.

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Community Healthcare Cooperatives

Wayne Anthony, M.Div, MBA, SPHR (Senior Professional in Human Resources), Business Resource Center, The Pastoral Institute, Columbus, GA.
706-649-6400, [email protected]

The solution for many of America's healthcare challenges is the formation of Community or State Healthcare Cooperatives. In a Cooperative, employers and employees in an entire community could pool their healthcare dollars into a healthcare trust fund. Local trustees of the fund could contract with local and regional providers directly or through insurance carriers to provide services for all of their members and dependents at reasonable rates. Patients could choose which provider and services they want, and providers would be paid promptly. Such a structure already exists - ALMOST!

The structure being recommended is a community or state Voluntary Employee Beneficiary Association (VEBA). VEBAs were established in the Employee Retirement Income Security Act of 1974 (ERISA). Over the years, it has been refined by various IRS regulations and tax reform acts. Thus, it is a tried and tested body of legislation and regulation. Moreover, it has broad acceptance from both political parties, business and labor organizations, government agencies and professional entities.

Congress needs to provide three clarifications: first, allow anyone in the same geographical area to join rather than limiting it to employees "engaged in the same line of business;" second, allow Healthcare Savings Accounts (HSA) that roll over annually and are portable; third, clarify the use of funds for non-taxable wellness, sickness and accident benefits when provided by qualified 501(C)(3) healthcare organizations.

All of these clarifications fall within the original intent of the Congressional legislation, which was to allow employees from ten or more small employers to collectively form a healthcare trust in order to purchase healthcare on a broader risk-sharing basis. Because of the restriction embodied in the phrase "same line of business," small businesses have been unable to utilize such a healthcare trust. Instead, VEBAs have been used extensively and successfully by large and mid-sized employers.

A Cooperative would make it possible for all employees in the same geographical area to participate in a collective healthcare trust and to purchase healthcare services, including wellness, sickness and accident benefits. A Cooperative will benefit employees from organizations of all sizes, especially employees and their families in small businesses who cannot access large group discounts or who are not covered at all because their company cannot afford benefits. The Cooperative has the added advantage of putting employees and their representatives in the position of designing the benefit plan, while at the same time having fiduciary responsibility for the financial solvency and stability of the trust. Moreover, it gives employees and their dependents more choices regarding health plans, healthcare providers and health services.

Providers benefit because plan designs and reimbursement are actually directed by the people who pay for and use the services. It puts purchasers, participants and providers of healthcare back in charge of healthcare and its delivery system. Equally important, the Cooperative encourages, reimburses and rewards wellness, prevention and healthy life styles.

A Cooperative arrangement could dramatically improve the way healthcare is delivered, simplify how it is paid, and include far more Americans in viable, affordable healthcare coverage. Indeed, what is proposed is a simple but significant amendment to the VEBA guidelines that would facilitate the design and intent of the original legislation. Obviously, a Community or State Healthcare Cooperative could have a very positive impact on healthcare for employers, employees, families, unions, physicians, hospitals, clinicians - indeed, all purchasers, participants and providers of healthcare in this country. It could well be the most significant healthcare legislation enacted in years and be the most positive healthcare reform introduced in Congress in decades.

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Balanced Choice Health Care System

Ivan Miller, PhD, psychologist and psychotherapist in private practice, Boulder, CO.
303-499-3888, [email protected]

The Balanced Choice Health Care System (Balanced Choice) offers a new paradigm for restoring to health care the normal economic forces that create lower prices, improved quality and greater accessibility of services. It is more effective and efficient than either the paradigm of traditional insurance or the paradigm of a traditional single payer system. By combining ideas from single payer proposals and market systems and adding innovation, Balanced Choice proposes a change in the way of thinking about financing health care. This proposal satisfies the major concerns of all stakeholders (patients, providers, and employers) and provides all Americans with both complete health care security and freedom of choice.

First, the proposal presents the thirteen points that explain the structure and organization of Balanced Choice. This is followed by a summary of the four improvements that Balanced Choice shares with a traditional single payer system, nine innovations that are unique to Balanced Choice, and seven additional advantages of Balanced Choice.

Second, the Balanced Choice Pharmacy Benefit System is explained in detail as an example of how it restores normal economic forces, and how it simultaneously provides both health care security and pressure for lower prices, higher quality, and greater accessibility. The pharmacy benefit is the one part of Balanced Choice that can be implemented, independently of the entire proposal, as a Medicare Pharmacy Benefit Program. If implemented in Medicare, it would not only serve Medicare beneficiaries, but could also control the excessive price increases in the pharmaceuticals market.

Third, the theoretical problems in other proposals are reviewed and followed by a brief presentation of how Balanced Choice restores normal economic forces.

Fourth, using 1999 health care costs, Balanced Choice proposes a financing plan that can fund universal coverage while offering an overall savings of combined taxes and insurance costs to all stakeholders - employers, consumers, and providers.

Fifth, although as an innovative paradigm shift, Balanced Choice may appear complicated, in reality it is easy to use, and it operates like other parts of the free market system. To demonstrate how it works in practice, its impact on each stakeholder is described. Brief vignettes that illustrate the choice-making processes of consumers and providers are included.

The explanation of Balanced Choice is followed by a section describing how it meets the contest terms and conditions. Balanced Choice offers a point-by-point response to the Health Care Magna Carta, along with a listing of the Balanced Choice principles. It outlines the requirements for accountability and responsibility for all participants, the overall plans for regulation, a management structure plan, a transitional proposal, and an innovative design for advocacy and oversight.

Overall, Balanced Choice is a proposal that truly meets and balances the needs of all stakeholders and offers a reasonable solution for problems in the health care system. It converts health care from a uniquely complicated system to one that is no more difficult for consumers and providers to use and understand than the choices they make in the grocery store. Moreover, Balanced Choice restores healthy economic forces that press for lower prices, higher quality and greater accessibility.

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Foundations of a New Health System For the United States

Elizabeth A. Pavka, MS, PhD, and S. Samuel Shermis, M.Ed, PhD, are from Asheville, North Carolina. Dr. Pavka is a nutritionist and Dr. Shermis is a retired university professor.
828-252-1406, [email protected]

This proposal is divided into seven chapters.

Chapter 1, the Introduction, specifies the problem: the American health system is seriously flawed and suffers from a wide variety of defects, ranging from costs that are increasing alarmingly to a large number of individuals who are not being properly served. The second part of the introductory chapter lays out the organization of the remaining six chapters.

Chapter 2 summarizes three processes which were used in writing the proposal: gathering information, Banathy's social system design process, and our assumptions.

Chapter 3 presents the authors assumptions concerning health. To expand upon this, they turn to some seminal statements of Dr. John Kitzhaber who raises fundamental questions usually ignored in the attempt to discuss how to pay for a health system. Kitzhaber's questions revolve around the benefits of health, the costs of illness to the health system and to individuals and society, and the benefits of illness to the health system. Agreeing that the dominant biomedical model does well with certain kinds of illness, the chapter discusses a second model, wholistic in nature, and concludes with an integration.

Chapter 4 develops the assumptions and procedures by which the proposed health system will be financed. It deals with the concept of investing in health rather than paying for illness. It argues that all those who benefit from the health system must pay for it. A new source of income for the health care system called "Sickness Treatment Surcharge" is explained.

Chapter 5 presents the model of the new health system. It introduces some basic concepts and employs a novel attempt to translate the model into practice: by utilizing the life story of one person, a woman born in 2010 and dies in 2110.

Chapter 6 shares an implementation timeline.

Chapter 7 contains the summary and conclusion.

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Building an American Health System

Joan Richardson, MD, primary care physician in private practice, Miami, FL.
305-443-8654, [email protected]

In building an American health system, the goal must be provision of health care to everyone. This is a national priority. This system must be uniform and easily accessible for the national (e.g. Medicare, Medicaid) and international (e.g. Britain's National Health Service) government programs in combination with the commercial sector of health service leaders are appropriate models. Using the systems and components that are successful in these entities will be the foundation.

The system will be managed through the government and insurance companies. The government seems most experienced and prepared for the task as an infrastructure already exists through the Social Security Administration and other government agencies. In addition, the information technology infrastructure is already in place. This provides the most extensive database of the nation's health care recipients that would be accessible to physicians and hospitals. This should ensure that all have access to the best comprehensive quality health care.

In order to attain the above, the employer-based model would be phased out. Purchasing health insurance from the government will subsequently be available to everyone. Each person will pay directly for services at prices comparable to Medicare and Medicaid fees. Through the Public Health Service all preventive screening will be done without charge. This will lead to a healthier people and a health system that takes care of everyone.

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State Resident-Based Health Insurance

Rollins School of Public Health, Emory University, Atlanta, GA.
Marissa Scalia, Team Leader, 678-596-8436, [email protected]

State Resident-Based Health Insurance (SRHI) addresses the failures of the current U.S. health care system by combining features of both public and private systems: insurance plans will still be operated privately, but plans will be negotiated by the states according to state regulations. SRHI successfully meets the objectives outlined in Kathleen O'Connor's "Health Care Magna Carta of Rights and Responsibilities." SRHI is a decentralized system in which the federal government delegates responsibility to and oversees the states, thus setting central standards while offering local flexibility. Under SRHI, everyone will have access to adequate preventive, diagnostic, and therapeutic services that will be provided using traditional outlets such as primary care providers as well as a network of public health centers. Features of SRHI such as computerization of hospital systems and evidence based guidelines for the lowest-premium plans ensure greater efficiency and cost-effectiveness, thus lowering the cost and increasing the quality of health care.

SRHI is modeled after the Federal Employees Health Benefits Program (FEHBP) and will build upon each state's employee benefits plan. The federal government will collect income taxes, payroll taxes, and general revenue; distribute money to states and territories; and regulate SRHI in each state. The state governments will use federal money, revenue from state taxes, and premium contributions of residents and businesses to support a state-based system of insurance. The states will negotiate with health insurers to provide a number of health insurance plans from which state residents can choose.

Employers will pay a percentage of the premium of each of their employees designated as the primary policyholder based on the employee's employment time status. The amount each employer contributes per employee will be calculated by each state based on the median-priced premium and prorated for employees working less than full-time. Small businesses, as defined by each state, can apply to receive subsidies for premium payments.

Residents will choose one of the state negotiated plans. Residents will pay a premium; they will pay a larger premium if they select a more expensive plan. Each resident will be responsible for a sliding-scale co-payment that is reflective of income. Unemployed residents who are not the spouse or child of an employed resident will select from among the plans offered in the state, but will not have the benefit of an employer contribution to their premium. Impoverished families and individuals, whether or not they are employed, may receive state assistance with paying their premiums and deductibles but will have less plan choice than other residents. During an implementation period of seven years, Medicaid and Medicare will be eliminated and their populations will be integrated into the SRHI system.

SRHI is, therefore, a solution to the problems of the current health care system that ensures everyone access to health care services through health insurance coverage.

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A Healthy America: A Proposal for Reforming the United States Health System

School of Public Health, Loma Linda University, Loma Linda, CA.
S. Eric Anderson, Faculty Advisor, 909-558-4300, ext. 47109, [email protected]
Dora Barilla, MPH, CHES, Doctoral Student, 909-944-3225, [email protected]

Concerns over healthcare costs, quality, and accessibility are growing nationwide. The root causes of the healthcare crisis are complex and have been escalated by fragmented legislation that has attempted to solve the challenges. Solutions to our healthcare crisis will not be solved until the underlying driving forces of our system are addressed adequately. This proposal takes healthcare in a direction that will benefit the nation as a whole and will address the fundamental issues that continue to decay our current health system.

The following proposal will describe an ideal health system. This system will have a national body that will define and establish basic healthcare coverage. Healthcare will be seen as nothing more than a public utility that is available to all citizens. Individuals and families will receive vouchers from the government to purchase basic healthcare coverage, ranging from $2000 to $18,000, depending on health risks.

The financing mechanisms for proposed system will be:

$624 billion - the current dollar amount spent on healthcare by the federal government
$420 billion - increased co-pays, deductibles and out-of-pocket fees
$200 billion - tobacco and alcohol taxes
$50 billion - additional taxes levied against products with significant health risks
$170 billion - additional revenue as United States Corporations become more profitable, as they no longer will be paying for their employee's healthcare, and pay more in taxes
Total = $1.464 Trillion Dollars

The management of the proposed system will be by an appointed Health Commissioner at the federal level with appointed state and county Directors of Health Services. Each county will have a regional board comprised of representatives from all healthcare stakeholders, including individuals. The Health Commissioner, state and county Directors of Health Services, and local boards will be responsible for the financial management, establishment of benefits, quality assurance, and other functions. The Health Commissioner will be appointed and will oversee the appointments of Healthcare Directors for each state and county. With government support and backing, the proposed system can be successfully implemented in two years.

The revised system will include the development of special medical court staffed with expert judges. These tribunals can screen claims, determine liability, and set economic damages and apportion settlements based on an established standard schedule. By capping the awards for damages, all people involved in the process will receive fair and equitable reimbursements without threatening future sustainability of the healthcare system.

In a healthcare system designed to benefit all individuals residing in the country, everyone must be made accountable, and must assume their responsibilities.

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A New Paradigm for The Public's Health

Gerald Tracy, JD, and Terri Clark CNM, MSN, PhD, live in Connecticut. Gerald Tracy provides corporate legal counsel for Hartford Insurance and Dr. Clark is on the faculty of the School of Nursing for Yale University.
Gerald 203-874-5346, [email protected]; Terri, 203-737-2546; [email protected]

We propose an American health care system that is based on four essential principles:

First, each American citizen has a fundamental right to medical care, available to all just as police protection, electric power, water, state and federal highways, and public education are available. Access to essential medical care should not be a benefit granted by one's employer, or an entitlement based on one's age, economic status or medical condition.

Second, control of delivery and financing of American medical care is too important to the personal health of its citizens to be left to the experts: whether medical professionals, managed care organizations, employers, or the federal government. Medical care should be governed by the people and for the people at a fairly local level of government.

Third, citizens should move from the periphery of our health care system to the center of the system, a center now dominated by private payers and private practitioners. This change is most effectively accomplished by organizing essential medical services as a public utility.

Fourth, the public medical care system should be organized and managed in order to:

Recruit and retain health care professionals whose priorities are high-quality and compassionate medical care;
Remove the financial/administrative elements in the current system that impede quality, (e.g. establish service-neutral provider compensation; replace fault-based malpractice system with no-fault system); and
Support these professional caregivers in continuous quality and service improvements.

This public medical care system is not a national health insurance model, but is based on a governmental initiative older and more successful than Medicare: American public education.

We propose that our country establish a health care system modeled after our education system. Everywhere in America, communities would fund and operate public medical care systems, making essential medical services available to all citizens. This system would be required under coordinated federal, state, and local laws, be funded primarily by state taxes, and be governed by local and state boards. The public medical care system would guarantee citizens access to basic medical, diagnostic, hospital, pharmaceutical, dental, behavioral and rehabilitation services-at little or no cost. Beyond these services, individuals would be free to use their own personal funds to purchase additional health services (e.g., health promotion, wellness counseling, performance enhancement) from private practitioners and programs. But everyone would pay into the public medical care system: citizens, businesses, and all levels of government.

We present the rationale for direct consumer control of both the delivery and financing of core medical services. We explain how this consumer-centric model effectively balances stakeholder interests with stakeholder responsibilities. We argue that the American public may be ready at this historical time, after 70 years of private-payer, private-provider dominance, to consider trusting their health care to their own American democratic process.

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HealthAmerica: It's good for all of US

Mary Jo Briggs, MPA, RN, team lead, Seattle, WA.
206-297-8304, [email protected]

This proposal centralizes the financing and administration of health care at the national level while strengthening the private delivery of care at the local level. It consolidates many government healthcare programs and employer programs and removes much of the healthcare burden from the states. Utilizing multiple sources of funding including employment taxes and an income tax component, the HealthAmerica plan covers a broad array of services for all legal residents.

Healthcare delivery is strengthened in three main ways:

Coordinated care across the full-spectrum of services is required and rewarded by the structure.
Evidence-based medicine and shared-decision making with patients is built in.
Comprehensive and near-universal coverage of individuals produces an economy of scale for innovation, cost reduction on a per capita basis, and quality improvements.

HealthAmerica builds upon the successes of the Medicare Program, improves it, and expands it to all Americans. The plan diminishes health care administrative redundancy at the federal level, simplifies the multiple insurers for patients and providers of healthcare, and allows employer and employee groups to move beyond the escalating battles over healthcare benefits. Lastly, it will increase consumer confidence for both young and old, resulting in increased productivity for our nation and the quality of each of our lives and our families' lives.

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Rex Green

Rex Green, Medical Silicon Valley Section, Health Care Discussion Group, Cupertino, CA.
408-255-0671, [email protected]

Our proposal for revising the way healthcare services are delivered stresses the development of caring relationships with each customer who needs services. The customer must pay for service and have an equal say in which services she needs. Customers will be trained to seek those services that promote better health, thus preventing health problems from occurring or growing worse. Customers will be able to access their medical record at any time and schedule visits or make phone calls to one clinician, who will manage a caseload of customers. A dialog will ensue between these two people in each relationship over what services are needed and are most beneficial.

Two types of prepayment of services are recommended. Health services required by most people, as a matter of course, will be contracted for with payment going from the individual or family directly to the organization that hires the clinical staff. The contract will specify how much is owed per month for covered services. Most people will purchase an insurance policy to cover unexpected, expensive health services, such as resulting from a devastating illness or injury. We recommend that in current dollars $10,000 or two inpatient days be the cutoff: the health services organization will cover up to $10,000 per illness or injury, while additional costs of services for unusual health problems will be paid for by the insurance company. Most customers will purchase contracts and insurance policies by paying a monthly fee for each.

A government agency, probably the Center for Medicare and Medicaid Services (CMS), will be tasked with promoting competition within designated market areas and will authorize persons qualifying for government-funded health insurance to receive services from those health service organizations that become ISO-certified as having a quality management system. This agency also will monitor the catastrophic health insurance policies their clients purchase to ensure that risk pools are appropriately defined and the rights of their clients to needed services are guaranteed in the policies. Once the government begins paying their clients to obtain health services, Public Health Departments at state and local government levels will be charged with educating potential customers on how to shop for services and how to become a proactive customer. Educational programs and advertisements will be designed based on prior health services research findings as to how customers benefit most from participating in the decisions as to which services and when.

The transition from current forms of health delivery to this collaborative approach will evolve with time, starting from models of consumer-driven care now being explored. Increasingly, employers are setting up medical accounts for employees to draw upon to pay for medical services. When the account is drawn down, the employee pays out of their own pocket for any more services. On the provider side, medical groups are emerging that only accept "cash" and offer all needed medical services to their customers around the clock. By establishing a collaborative model on a trial basis in some medical groups, health services researchers will be able to determine whether our approach succeeds in promoting higher quality care at a lower cost. If we are correct, then more employees, and self-employed persons will hear of this type of care and become customers. Just as with HMOs, cheaper services of higher quality will gradually attract more customers, eventually coming to the attention of Congress and advocates who will lobby for extension of this approach to clients of CMS.

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Evan Fieldson

Evan Fieldson, MD, MBA, Philadelphia, PA. [email protected]

If the nation is serious about reforming its $1.4 trillion health economy with more choice by patient-consumers, it must confront many issues, including uninsurance and underinsurance, waste and fragmentation, the costs of chronic illness, the incompatibility of insurance principles with chronicity and consumerism, the needs and costs of medical education and research, and demographic and demand facts. A hybrid of mandatory, voucher-backed private health insurance (HI) with some form of government "reinsurance" for chronic illness is a proposed solution.

Basic Rules: Using tax revenues, the federal government passes vouchers to all 284 million Americans that will cover 100% of the cost of at least basic acute/catastrophic health insurance coverage. The value of the voucher could vary by broad age groups. Funds from all separate federal and state health insurance and entitlement programs are moved into this system. The value of this is about $533 billion.

Health insurance is de-linked from employment and individuals use vouchers (+/- cash add-on) to purchase HI to cover basic, acute, and catastrophic care (+/- more extensive options).

A government fund is created to reinsure (some of) the extra costs of chronic illness and special needs (the non-insurable risks) and pay for coordination. The value of this is about $700 billion.

Copayment structures are reorganized so as to capture socially beneficial treatments, for example with rebates and bonuses to patients for their compliance.

Payments to providers are on a fair, honest basis without massive cross-subsidization from one payment type for another. Providers compete on quality (i.e. patient satisfaction, employer satisfaction, readmissions, ER visits, morbidity, mortality) and cost.

Government continues to fund research, education, and public health, but as direct budget items and not as flow-through in Medicare or other programs. This amounts to approximately $200 billion in spending.

The marketplace may not achieve goals like uniformity, electronic medical records, or information technology upgrades without government support, incentives, or requirements. A government board might operate to give central standards and management of financing and regulation that also allows for local flexibility and variation.

Many other details, including the use of medical savings accounts, possible carve-outs, and the way that indigent populations are handled, would need to be worked out, but all should find a home in such a simplified system. The issue of medical liability might be addressed with a workers-compensation-like medical error fund. The costs of undergraduate medical education could be supported by contributions from industry (i.e. pharmaceutical and device in a coalition fund).

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A Legislative Plan For Universal Health Care Coverage: The Washington Health Security Trust Proposal

Robert Fithian, MD, Seattle, WA. [email protected]

The Problem: Based on the 1992 Washington Health Care Commission Report, econometric consultations we commissioned, and a more recent litany of governmental, news, and anecdotal reports, there is a health care financing crisis in the state of Washington. Health economist Frank Fox estimated total health care spending in Washington for the year 2000 at $20 billion(1). In 2002, Boeing official Bob Watts made the same estimate of $20 billion per year(2). About 45% of that comes from employment-based health coverage, 40% from existing state and federal government programs, and 15% from out-of-pocket individual payments for premiums, deductibles, co-payments, and noncovered items like prescription drugs.

In spite of this enormous expenditure for health care, more than 600,000 residents of Washington have no health coverage at all. Many others are underinsured or fear they will lose whatever coverage they have. Individual health insurance is increasingly unaffordable or unavailable. Employers are reducing health benefits as insurance rates skyrocket. Costs of the state's health care obligations are increasing much faster than other budget items and are a major cause of the budget deficit. The Basic Health Plan has been forced to reduce enrollment. Doctors and hospitals go out of business, operate at a loss, merge and downsize at a pace never seen before. 80% of surveyed Washington voters and doctors blame the mess on insurers(3). However, many insurance companies and HMOs also cannot survive in the present chaotic market environment.

The Washington Health Security Trust Proposal
We propose creating the Washington Health Security Trust, a single public trust fund dedicated to finance a defined set of health services for all state residents. We present our proposal as part of a State-by-State strategy to achieve national universal coverage. Our proposal moves the amount of money now spent on health care from current sources into the trust. The trust can cover health care services for all residents without additional revenue.

Highlights
All residents are covered for defined benefits regardless of health or employment status. Residents choose their providers. Providers and patients make the medical decisions. Doctors and other providers work in the private sector, just as they do now. They are not employees or agents of the trust. Physicians, clinics, hospitals, and other providers negotiate the terms of their participation with the trust. A public board of trustees governs the trust. The initial appointed board, using citizens' and technical advisors, defines the benefits package, establishes a simplified claims processing system, and creates scientifically based tools for monitoring performance. The subsequently elected board of trustees and its advisory committees monitor operations, financial performance, the benefit package, quality of health services, and public satisfaction. They are directed to seek public input for trust policies over time. The initial appointed board is accountable to the governor and the legislature. Once the trust is up and running, elected trustees replace the appointed trustees in an orderly sequence and are directly accountable to the voters in their congressional districts.

How the Trust is Financed
The Washington Health Security Trust is funded by a combination of sources chosen to resemble current health spending patterns and to work with specific limitations and unique provisions of the Washington tax system.

Employers pay a health security assessment of 10% of payroll above a threshold of $125,000 per quarter.
Residents 18 and over pay a health security premium of $75 per month (except Medicare enrollees).
Medicare enrollees pay a premium of $50 per month to add trust benefits beyond their Medicare benefits.
State funds for health programs are transferred to the trust. Whenever the trust obtains federal waivers, funds for federal health programs will also be transferred to the trust. Until then, federal patients will pay affordable co-payments for outpatient and emergency visits, prescriptions, and long term care.
Certain exemptions are included for low income families and employers facing financial hardship.
Employers may purchase private health coverage for their employees. However, the trust benefits package is intended to give employees better coverage than the best current health benefit plans, which now cost employers 12-14% of payroll.
Pooling the funds for health services across the state and spreading the risk across the entire state population provides a stable mechanism to finance quality care for every resident.

The Health Security Trust is a simple, fair, accountable, and affordable system to fund necessary health care for all residents of the state of Washington.

(1) Health Trends, Frank Fox, 1998-2000
(2) Watts, Bob, Report from Facing the Future Conference (DSHS), 12/06/2002
(3) Elway, Stuart, Elway Research, Inc., WSMA Polls, 1999

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Jeff Inglis

Jeff Inglis, journalist, Portland, Maine. 207-749-4502, [email protected]

This proposal is based on the principles in the Health Care Magna Carta at www.oconnorhealthanalyst.com/magnacarta.html and included in Appendix 1. It is important that sweeping change in the U.S. healthcare system take place in a short period of time. This document lays out the changes and transition plans, as well as an ongoing plan for funding and support for a new style of healthcare system, which will result in high-quality affordable healthcare for all Americans. The problems are legion and well-known: cost shifting from government onto the sick and the infirm; lack of choice for medical expense coverage, leaving either an all-or-nothing plan, or payment out-of-pocket for everything; money sqaundered providing insurance rather than care; and lack of individual choice of care, provider or payment method.

The opening moves in this renovation of healthcare can only be made by government, which is the sole group with the power to bind itself and others to a process of change.

Therefore, the Congress shall enact, and the president shall sign, a sweeping healthcare reform bill based on the principles that the U.S. government is bound to protect the interests of all Americans; many Americans have no healthcare and many more have trouble affording it; and it is the duty of Congress to act to cause healthcare to be accessible and affordable to all Americans.

Contained within that legislation will be:

A continuation of Medical Savings Account laws, with some important clarifications.
Malpractice liability will be capped, limiting liability for all medical professionals and facilities.
Reform prescription drug coverage.
Reforming government administration of Medicare and Medicaid.
Providing incentives to businesses to participate in this new system?
Creating national, regional and statewide health planning boards to allocate healthcare resources effectively across the nation.

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Michael Moody

Michael Moody, MD, Newnan, Georgia.
404-331-5001 ext. 2092, [email protected]

The health care system in the United States is at a crisis level and changes need to be made immediately. This country has the resources to provide high quality health care at affordable prices; however, Americans have to stop talking about it and start actively seeking solutions to the problems that exist. The health care issue must be broken down into smaller segments to avoid being overwhelmed. Issues such as funding, patient care, and medical insurance need to be addressed as individual topics rather than grouping them together.

We must harness the power of our existing government agencies to help keep the costs to the medical consumers and providers of care at an affordable level. Insurance must be regulated to allow patients the right to choose their own care providers. Universities need to streamline their health care programs to prevent long waiting lists and adapt to the schedules of working adults. Care providers such as nurses and therapists have to be given the authority to use their skills if an emergency situation arises. Most importantly, doctors and care providers must improve their communication with one another to make sure that the patient is receiving the best treatment possible. The time is now. Let's get going!

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Integrated Medicine Wellness Cooperative (ImWell)

Louise Moorhead, MD, Houston, Texas. 713-928-3375, [email protected]

The health care system in the United States is in crisis with over forty million uninsured Americans and untold numbers of under-insured Americans.

ImWell is a new approach to American health care based on a modified version of the principles outlined in the Health Care Magna Carta proposed by Kathleen O'Connor, July, 2002.

ImWell embraces a business model first developed in America's heartland - the non-profit cooperative (Co-op). The strategic goals of the ImWell Co-op shall include open membership, preventative medicine, integrated medicine, client-centered medicine, risk mitigation (via binding arbitration), and increased efficiency (via several state-of-the-art technologies).

ImWell shall be financed by monthly member dues. An estimated 50 million Co-op members shall provide an annual budget of 30 billion dollars. Surplus revenues shall be returned to Co-op members on an annual basis.

ImWell shall provide high quality, low cost health care in four tiers of coverage: 1) local; 2) district; 3) regional; 4) national.

ImWell shall stress the privileges, responsibilities, and accountability of all members. Members who abuse privileges and/or fail to carry out responsibilities shall risk suspension or cancellation of membership.

ImWell shall initially be marketed to low and moderate income clients (individuals and families) and small businesses using several different approaches.

ImWell shall require NO regulatory changes to start and very few regulatory changes to achieve complete coverage and services for all Americans.

ImWell shall be managed hierarchically. A member-elected Board of Directors comprised of clients, providers, and health care support industry professionals - all unpaid volunteers - shall be at the reins.

Implementation of ImWell shall not happen overnight, but an ambitious, but "doable" 18-year plan shall bring about most coverage and services.

ImWell shall achieve effective oversight through a member-elected, autonomous mediation board.

ImWell is the future of health care in America.

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Health Reform Even Republicans Can Like!

E. L. Rafetto, San Diego, CA. [email protected]

What Will It Take Before Everyone Has Access to Healthcare? When President Kennedy made getting to the moon a national cause, the mobilization of government, academic science, and industrial initiative were mixed together with enough money to get the job done and done with such single-minded purpose that even today it is nothing short of amazing. We have yet to achieve have that same single-mindedness with regard to resolving healthcare delivery so that it is accessible for all Americans.

Arguments abound as to what is wrong with little consensus. Solutions abound, but always seem to cater to one special interest or another. And those special interests often lobby fiercely to maintain a status quo that preserves current profit levels. The lobbyist's work is made easier given that health plans' public and private, operate in an adversarial, accusatorial or confrontive manner towards providers and the public. Divide and conquer works all too well in the dysfunctional US healthcare delivery system.

By attaching health care access to employment we have disenfranchised over 42 million people, preventing them from getting adequate healthcare on a timely basis. There is nothing about our present health delivery system that puts people first. Our priorities are skewed so badly that our political leaders substitute HIPAA and hype because to address the really tough issues leading to solutions would impact campaign war chests and their ability to get re-elected. Every law attempting to improve accessibility contains language that excludes people and provisions that seem deliberately complex. It's like rebates. The ads always show the sale item after the rebate, but industry leaders know just as well as politicians that many people don't apply for rebates and aren't likely to go through whatever hoops are necessary to be eligible for vouchers.

So far, I haven't seen any political leader taking the bull by the horns and promoting a healthcare delivery system that covers everyone. But, I do know we desperately need an impartial consensus-builder to lead the way.

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Medicare for All: Because It's Your Right and America's Responsibility

University of Washington Health Administration Student Team, Seattle, WA.
Jennifer Mas, contact person, [email protected]

MEDICARE FOR ALL is presented here as an alternative model for the United States health care system. It builds on the successes of the current Medicare program for people 65 years and older, the lessons from other industrialized countries, and the priorities of Healthy People 2010, the federal government's national health objectives. We use the term Medicare because it is widely understood and appreciated as a health system available to people regardless of residence, income, or social status, and offering a wide range of services, with low overhead costs.

Our aim is to take these successful models to achieve the following goals:

Rein in health care expenditures;
Provide access to health care for all populations;
Improve the effectiveness and efficiency of health care delivery;
Decrease health disparities, and;
Improve basic health status of all Americans.

MEDICARE FOR ALL encompasses features that promote accountability and responsibility among all parties: individuals and families, health care providers, taxpayers, and public officials. Most especially, we have structured the program in a way that respects the history in the U.S. of shared responsibility for health among federal, state, and local governments.

MEDICARE FOR ALL is managed by three governing bodies. The National Health Board is comprised of individuals appointed by the President and confirmed by the Senate. The Board is responsible for allocating funds to states, setting minimum performance standards, setting minimum benefit packages for Americans, regulating licensure of the health professional workforces, developing and monitoring evaluation tools for states and serving as a clearing house for states to disseminate information about best practices as well as health status indicators. The State Health Boards are comprised of a representative sample of the population. They report to the National Health Board and are responsible for attaining goals for service effectiveness and efficiency, quality, expenditure growth, and health status. Local Health Districts are governed by a board of individuals elected by district residents and are responsible for coordinating and planning health services and public health activities in their respective areas to assure access, improve health, and avoid unnecessary duplication of services. They report to the State Board of Health. Health providers continue to operate as they currently do, but receive global budgets from their local health district.

Financing for MEDICARE FOR ALL comes from national progressively levied individual and corporate income taxes that will finance 75% of the cost of the health system. Another 15% will be supported through individual premiums, collected through payroll deduction (or, for non-employed people, through the IRS tax collection system). These premiums will be assessed on a sliding-scale base, with zero cost for those at or below 100% of the federal poverty level, and full premium share for those at and above 300% FPL. Another 10% of the cost will be collected through co-payments at the time of service for all services except prevention services that have been proven effective. The existing Medicare payroll taxes are eliminated, as are employer-paid premiums and the tax deductions for employer-sponsored coverage. The current Medicare Trust Fund will be used to finance MEDICARE FOR ALL.

States are not limited in how they spend money allocated to them as long as they meet the basic tenets of MEDICARE FOR ALL.

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Build an American Health System

Terry Worthylake, Vancouver, WA. 360-882-7782, [email protected]

Our American health care industry has an abundance of shining examples of skilled professionals, world-renowned hospitals, miraculous technical and drug innovations and thoughtfully designed benefit plans for bringing such resources to bear on the needs of our citizens. What it does not do is make the health care services adequately available to all of our citizens. Millions of people have no insurance; additional millions are temporarily without coverage during the year. Many of those that do have coverage receive it through their employment, making it subject to the financial health of their employer.

We have health care services that could be available to everyone but we do not have a national commitment to providing an economic basis that would enable everyone to obtain the services. The attached "Magna Carta" sets forth requirements for the foundation of a national system that deals with the health care needs of the public as a whole without losing the best features of what we have already.

The Magna Carta includes several key requirements. There should be: (1) a common health care risk pool for all of our citizens; (2) people should be more directly involved with their health plans (both intellectually and financially); (3) no one should be made destitute by the cost of their care, and; (4) there should be basic plan standards as well as a variety of well, and simply, described options to choose from.

These objectives can be achieved with the resources at hand with some modest enabling legislation, a few incentives, incremental benefit funding and centralized system oversight.

A national risk pool can be created with existing insurance companies by the government sharing risk with them as a vehicle for networking insurers together to underwrite a common national high deductible plan. The standard high deductible could initially start at a fairly high catastrophic level and expanded as funds became available. The plan could be interfaced with credit and savings arrangements as well as a good selection of existing or new "first dollar" coverage plans.

The standard plan would be complemented with a limited amount of consumer credits for screening visits to providers, revised bankruptcy protection for excessive medical expenses, incentives for providers to form more effective and culturally sensitive integrated delivery systems, a politically acceptable tax base and the government enabled detachment of benefit coverage from employment.

A new, comprehensive, national health care system can be achieved. We have the resources and the tools to do it. Given the right direction, legislation, management and funding it is well within our reach.

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Medicare for All

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Balanced Choice Health Care System

Foundations of a New Health System For the United States

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State Resident-Based Health Insurance

A Healthy America: A Proposal for Reforming the United States Health System

A New Paradigm for The Public's Health

HealthAmerica: It's good for all of US

Rex Green

Evan Fieldson

A Legislative Plan For Universal Health Care Coverage: The Washington Health Security Trust Proposal

Jeff Inglis

Michael Moody

Integrated Medicine Wellness Cooperative (ImWell)

Health Reform Even Republicans Can Like!

Medicare for All: Because It's Your Right and America's Responsibility

Build an American Health System