National Health Insurance: Advocating a Single Payer Health Care Plan
As a nurse educator in community health nursing, I am always amazed by the number of my colleagues and student nurses who respond with horrified looks when I advocate the need for a national health insurance plan for the United States (US). The shocked look on their faces is usually followed by a common remark, 'I have a friend (or family member) who lives in Canada and they have waited 9 months for a hip replacement (or some similar surgical procedure).' While I do not know their personal friends or family, I cannot help but wonder if their responses to a national health insurance (NHI) plan are fueled more by a lack of information. The US is the only industrialized nation that does not have some form of NHI.
Many people seem to think that NHI is a new concept. In fact, 5 attempts have been made since the early 1900s to bring NHI to the US (Harrison, 2003).
* 1915 - The American Association for Labor Legislation proposed a plan to cover medical care, sick pay, maternity benefits, and funeral expenses for low-income workers. This proposal was highly opposed by the American Medical Association (AMA).
* 1940s - Senator Robert Wagner and Senator James Murray presented a plan to expand social security to cover physician and hospital care for workers and retirees. Public opinion at the time was supportive (74%) of a plan to cover medical fees.
* 1945 - President Truman was the first president to support a NHI plan. Unfortunately, public support for his plan was less optimistic (38%). The AMA launched a massive campaign and defeated the plan.
* 1965 - Plans for Medicare and Medicaid were passed, although Medicare coverage was limited to people over 65 years of age. Medicaid was the first public assistance program which was need-based and did not require recipients to pay into a plan. Interestingly, Medicare was initially opposed by the AMA, although much of the public (61%) did support the inception of the program.
* 1970s - Senator Edward Kennedy proposed a program to provide single, universal health insurance for all citizens, which would be funded by employer and employee contributions and federal income taxes. Again, this bill was opposed by the AMA, the insurance industry, and President Nixon.
* 1990s - President Clinton proposed a mandated employer-based private insurance with governmentfunded public assistance. While this plan had substantial public support (59%), campaigns to oppose the plan decreased support to 40% and reduced momentum for legislation.
Today the US faces an economic crisis which has not been experienced since the Great Depression. Approximately 47 million people are uninsured and many more are underinsured (Single Payer, n.d.). While the US spends twice as much per patient than other industrialized nations, the US scores much lower on life expectancy, infant mortality, and immunization rates. Although these statistics seem grim, this may provide the window of opportunity to move legislation toward a NHI plan for the US. According to a survey by the Kaiser Family Foundation and the Harvard School of Public Health (Singh and Datz, 2009), reforming health care is one of the top priorities for President Obama and Congress. Surveyed Americans indicate that helping newly unemployed afford health insurance is a top priority (33%). Elimination of refusal by insurance companies for pre-existing conditions is favored by a majority of Americans (78%). Many citizens (65%) favor limiting administrative costs by insurance companies. Even groups who have adamantly opposed NHI in the past such the AMA, have begun to voice support for changes in health care. In a cross-sectional study (Rashford, 2007) to determine whether or not US physicians supported NHI, the researchers found that 49% of doctors supported legislation for NHI. Of the 49% who supported NHI, 61% favored a single federal payer system. Primary care physicians (71% of those surveyed) supported NHI compared to only 58% of nonprimary care physicians. The Physician's Working Group for Single-Payer National Health Insurance published an article in JAMA (2003) proposing a plan for NHI. A major component of this plan was to establish a single payer source through an expanded and improved version of the traditional Medicare program. Representative John Conyers (D-MI) introduced the Expanded and Improved Medicare for All Act (H.R. 676) (www.govtrack.us) to the 109th Congress in February of 2005. The bill would have provided for comprehensive health insurance coverage for all US residents. It was referred to several committees, including the House, Ways, and Means; and the Subcommittee on Health. Unfortunately, the bill never made it out of the committees. In January of 2007, Representative Conyers again introduced a revised version, US National Health Insurance Act (or Expanded and Improved Medicare for All Act) (www.govtrack.us). Again the bill was referred to the Subcommittee on Health. Since Congress sessions last two years, at the end of each session all proposed bills that have not passed are cleared from the books. Although the bill died in 2007, it did gain significant support with 93 cosponsors (Grim, 2009). Representative Conyers again will re-introduce his health care legislation through H.R. 676 in 2009.
Why an expanded version of Medicare one might ask? One of the major problems with the current US health care system is the multiplicity of insurers. Private health insurance companies utilize approximately 12% of premiums for overhead costs, yet Medicare overhead costs are only slightly higher than 3% (Physicians' Working Group, 2003). While taxes would increase, the increase would be offset by the elimination of insurance premiums and out-of-pocket costs. The elimination of multiple private insurance companies and their related-billing and paperwork procedures would significantly decrease administrative costs for hospitals, physicians, and other health care facilities. H.R. 676 provides a plan to retrain employees whose jobs would be eliminated by the reduced administrative duties associated with insurance and billing procedures. It is estimated that the current 30% of total health care spending would decrease to 15% due to savings on administration and billing. Additional savings would be realized by eliminating co-payments and deductibles, allowing preventative care to be encouraged. This is especially important for the most vulnerable populations - the poor and the elderly, who currently do not seek health care until it becomes a physical necessity. In the current system long-term care must result in virtual bankruptcy before patients are eligible for public coverage under Medicaid.
The ANA's Health System Reform Agenda (2008) supports a single-payer mechanism for financing a reformed health system. ANA is committed to the principle that health is a human right and all people should have access to quality care. Currently the majority of health care dollars are spent on secondary and tertiary care, instead of primary care. Nursing recognizes the need to reverse that trend and spend more on primary care, which would ultimately reduce the cost of secondary or tertiary care. This revised system should focus more on wellness and prevention of complications. The basic package of health services, available to all citizens through an expanded Medicare version, would be funded by payroll taxes and general fund revenues. Options for purchasing additional health services beyond the basic package would be available through commercial insurance companies. Health care consumers would only pay premiums and co-pays for care beyond the basic package. The ANA uses the analogy that the United States provides a basic education for all citizens. Why do we not provide basic health care for all citizens?
While it is beyond the scope of this paper to explain all the unique aspects of NHI, every nurse should be aware of the proposed plans. As H.R. 676 is being proposed again in the 111th Congress, it is critical that health care providers and citizens become knowledgeable of the bills being introduced. An alternative bill was introduced in the Senate (S. 334) by Senator Ron Wyden (D-OR) in 2007 which focused on universal care coverage delivered through private health plans (McArdie and Kometsky, 2007). Unfortunately, neither of these bills has received significant public attention. Nurses must be aware and need to make their voices heard. First, nurses need to explore and understand the proposed plans. Next, they need to talk with legislators and patients. Explain to patients what these plans mean and how care or finances may be affected by NHI. Americans are waking up and recognizing that the US can do a better job at providing health care for its citizens. The window of opportunity is open. Nurses should not let that window slam shut because they did not understand the proposed plan!
[Reference]
References
American Nurses' Association. (2008). Health System Reform Agenda. Retrieved 6/3/09 at http://www.nursingworld.org/MainMenuCategories/HealthcareandPolicylssues/HealthSystemReform/Agenda/ANAsHealthSystemReformAgenda.aspx
Grim, R. (2009). Conyers to introduce universal healthcare bill today. The Huffington Post. Retrieved 1/27/2009 at http://www.pnhp.org/news/2009/january/conyers_to_introduce.php
Harrison, B. (2003). A historical survey of national health movements and public opinion in the United States. JAMA, 289 (9), 1163-1164.
H.R. 676: Expanded and Improved Medicare for All Act. Retrieved on 1/27/2009 at http://www.govtrack.us/congress/bill.xpd?bill=h109-676
H.R. 676: United States National Health Insurance Act (or the Expanded and Improved Medicare for All Act). Retrieved on 1/27/2009 at http://www.govtrack.us/congress/bill.xpd?bill=h110-676
McArdie, F. & Kometsky, S. (2007). Wyden introduces universal health coverage bill: 'The Healthy Americans Act.' Retrieved on 1/13/09 at http://www.hewittassociates.com/Intl/NA/en-US/KnowledgeCenter/LegislativeUpdates/LegislativeUpdatesDetail.aspx?cid-3358
Rashford, M. (2007). A universal healthcare system: Is it right for the United States? Nursing Forum, 42 (1), 3-11.
Singh, R. & Datz, T. (2009). Health provisions among public's top priorities for economic stimulus. Retrieved on 1/29/2009 at http://www.kff.org/kaiserpolls/kaiserpolls011509nr.cfm
Single-Payer National Health Insurance, (n.d.) Retrieved on 1/27/2009 at http://www.pnhp.org/facts/single_payer_resources.php
Physicians' Working Group for Single-Payer National Health Insurance. (2003). Proposal of the Physicians' Working Group for single-payer national health insurance. JAMA, 290 (6), 798-805.
[Author Affiliation]
Roxanne Amerson, MSN, RN, BC
