- Email: [email protected]
The ethics of national health insurance: a personal essay
Clinics in Dermatology (2009) 27, 401–404
The ethics of national health insurance: a personal essay Steven Fenichel, MD ⁎ Atlantic City Medical Center, 2117 Bay Avenue, Ocean City, NJ 08226, USA
Abstract As the number of uninsured and underinsured American citizens increases, there is new interest in developing some sort of national health plan to ensure what many consider a basic right in industrialized countries. The debate is no longer merely between the “socialized medicine” advocates and those who believe the government should stay completely out of health care delivery. Now between those who agree that some sort of national health plan is necessary, there is conflict between the “incrementalists” and the “revolutionists,” who have differing ideas on how to best expand health care access to those without. © 2009 Elsevier Inc. All rights reserved.
Introduction
Background
In June 1976, I graduated from medical school in Ireland. On July 1, I started my internship at Mt. Sinai Hospital in Toronto, Ontario, Canada. On my first day, the Director of Medical Education called me for a short meeting. She presented me with an OHIP card for both my wife and me. I asked her what was an OHIP card? She proudly stated that OHIP stands for Ontario Health Insurance Program. I asked what does it do? She responded, “Any doctor or hospital anywhere in Canada is there for you if there is a need. If medicine is prescribed it is covered. If you have a mental problem, an addiction, dental needs, require eyeglasses… All you need do is present your OHIP card.” The answer still resonates within me 32 years later.
My years of training at one of America's premier inner city teaching hospitals, Cook County, as well as my years teaching residents and caring for mainly indigent patients at the Atlantic City Medical Center, have sensitized me to the inequities for the poor when it comes to health care. In addition, hearing the horror stories from family, friends, and neighbors concerning their experiences convinces me that real “Homeland Security” is “Health Care For All.” Several questions come immediately to mind when facing the early 21st century version of American medicine. What dermatology resources are available for the working poor? Poorly funded inner city hospitals often attract the most caring, passionate physicians committed to providing the best care for our poorest citizens. These include academicians and their residents, who work with the limited resources of publicly funded hospitals to care for “everybody and anybody.” Outside the dermatology clinics of these institutions, there are ever fewer private offices that will see Medicaid patients, let alone “charity” patients who have no insurance of any kind and cannot afford any payment. It is
⁎ Fax: +1 609 391 1806. E-mail address: [email protected]. 0738-081X/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.clindermatol.2009.02.014
402 understandable that there are limits to the number of patients that a dermatologist in private practice may see for severely reduced fees and keep the doors open, but rather than blame dermatologists for their lack of charity, we should look at how to improve a system that seems to be designed to send our less affluent patients begging. How does one access medication assistance programs for more expensive medications? Even a $10 generic antihistamine is beyond the financial reach of many indigent care and Medicaid patients. These patients are assisted by social workers, who spend their days trying to help patients obtain prescribed medicines. In the Cook County and Atlantic City Clinics, perish the thought of prescribing more sophisticated and expensive remedies such as biologic modifiers or even tretinoin cream. At the end of most clinic days, the social workers report that most patients leave without their medicines. Many pharmaceutical companies offer humanitarian assistance to obtain some of their newer and more expensive products, and of course, there are always those samples. This is especially important in the university clinics where our future dermatologists are being trained. It is possible to provide a patient with some samples of the latest and greatest topical steroid or retinoid and, after a bit of paperwork, even obtain a biologic therapy for psoriasis. The upside for the pharmaceutical company is that it gets a young physician in training used to thinking of its product as a first-line therapy. The upside for the patient who is allowed to use medications he or she cannot afford is all too often temporary: Eventually the samples stop coming, and the new dermatologist has to figure out another way to treat the patient. Even availability of high-cost therapies such as the biologics becomes more restricted once the big marketing campaign has drawn down. Perhaps a system where all necessary medications are covered would be better for all parties in this game. How does an uninsured patient get standard of practice surgery for a large periocular basal cell cancer? In years past, I cajoled, pleaded, and sometimes pestered plastic surgery colleagues into accepting an uninsured or Medicaid patient. Many of them were older physicians who have since retired. I have given up trying to find younger physicians to fill the void. Getting in line for the limited surgery slots at the university clinic is one option. Regretfully for many patients, the only practical choice is to wait until the lesion is so large and destructive that they become desirable teaching cases for the oculoplastics or otolaryngology program. This may be great for surgical education, but it is a lousy deal for the patient.
Universal coverage Universal coverage, and the possibility of a national health plan, was a political issue in the 2008 election but not as important an issue as it should have been. During the
S. Fenichel Republican primaries and ultimately in the party's campaign platform, the health care issue was hardly addressed, other than to restrict reproductive rights. Since “many a true word is spoken in jest,” satirist Stephen Colbert, in my view, hit the bulls-eye in describing the Republican health plan: It's so simple. Most people who can't afford health insurance are also too poor to owe taxes. But if you give them a deduction from the taxes they don't owe, they can use the money they're not getting back to buy the health care they can't afford. The Democrats were borrowing an idea from President Nixon in using mandates to coerce the people into buying insurance. The significant difference is that Nixon's mandate aimed to force employers to provide coverage for employees. Senator Obama's plan mandated that all parents, rich or poor, must buy insurance for their children. To see how this goal might be accomplished, we can look to the state where it is already up and running, Massachusetts. It is there that the Republican governor, with the support of State House Democrats (and even Senator Kennedy) initiated the “Massachusetts Miracle.” Viewed with a critical, objective eye, this “miracle” might be more aptly referred to as “fraud.” To achieve universal coverage, the plan mandated Medicaid for all citizens below 100% of the poverty level, such as a family of four earning less than $20,000 annually. For families at 100% to below 300% of the poverty level, the state was to provide partial subsidies. Above 300% of the poverty level, this family of four must buy health insurance or face severe a financial penalty. This penalty is much higher than violation of child labor laws ($50), domestic assault ($1000), or the illegal sale of a firearm ($500).1 Major problems quickly became obvious, especially for the group promised state subsidies. The uninsured were undercounted by 200,000 citizens. Most uninsured are too poor to afford that which most would consider decent coverage, and the “affordable” policies covered little. There was inadequate funding for promised subsidies, and most important, the administrative costs increased to the point that there were no cost savings. Clearly taking this model nationally would only result in failure on a larger scale. In my view, health care is an essential human right. Article 25 of the United Nations 1948 Universal Declaration of Human Rights states: Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or lack of livelihood in circumstances beyond his control.2 More succinctly, Dr Martin Luther King stated, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” But here in America, far from being a human right health care is treated more like a marketplace commodity.
The ethics of national health insurance: a personal essay In talks that I do on the subject of national health care, I ask my audience two questions: “What is America's health care ‘system'?” and “How much does it cost?” No one has been able to answer the first question. The second question is easier. Every February the national health expenditure figures compiled by government actuaries for the previous year are published in the journal Health Affairs. In February 2007, the total health care expenditures of the United States for the year 2006 amounted to $2.26 trillion!3 The actuaries project this amount will nearly double within 10 years to $4.132 trillion. This works out to nearly $21,000/yearly premium/individual. The annual premium for a family of four under this health insurance “plan” would cost $84,000. The other part of this expenditure that is not widely known is that 60% of this $2.26 trillion are public tax dollars. The American taxpayer is already more then half-way to funding a national health insurance plan without even knowing it. The Canadian system was robust in 1976 when I received the OHIP card, as judged by three criteria derived from studies at the Wharton School of Business: quality, access, and cost containment. Canada spends 10% of its gross domestic product to fund its entire health system, which is funded mainly by a progressive income tax in which those who make the most pay a greater share (up to 1.2% of the family income) for the national health plan. What they get from this covers all residents and citizens equally. America spends 16% of its gross domestic product for health care, and this is expected to approach 20% within the decade.4 What America gets for this massive spending is in stark contrast to Canada: 47 million uninsured people and many personal bankruptcies caused by bills for health care! These events are not occurring without pressure on and from the business community. In pursuit of the lowest employee insurance costs, employers are shifting more health care costs to their employees in the form of increased co-pays and deductibles. This is euphemistically referred to as increasing employee “personal responsibility.” Another aspect of the regressive American “system” is seen when an emergency arises. Imagine a motorist without health insurance is involved in a car crash with someone who has health insurance. Suppose that the injuries are identical for both parties, consisting of multiple broken bones and chest tubes to treat pneumothorax. After 5 days, both patients are discharged. In 10 days the uninsured patient gets a bill for $50,000. In 2 weeks the insured driver gets his explanation of benefits from the insurance company. His company approved $12,000 of his $50,000 bill. They agreed to pay $10,000 leaving the patient responsible for $2000. As luck would have it, the driver had a secondary insurance policy that was billed. The secondary policy paid $1500, and the patient was ultimately responsible for $500. This could be viewed a good or bad result, depending on the patient's financial status. The most important fact to recognize in this vignette is that the primary insurance company had a contract with
403 the hospital allowing it to pay 20 cents on the dollar! It is only the uninsured and wealthy foreigners who are charged “full freight” for their health care encounters. This practice of jacking up prices so they can be discounted for the participating insurance companies is known as “charge inflation.” The largest subsidy to the insured comes through the employers' tax write-off for employee health insurance. This federal subsidy is about 10% of total health care spending. Nationally, this subsidy in 2006 amounted to nearly $226 billion. Because everyone, including the uninsured, must pay their income taxes; their money helps pay for employer-based plans. And so once again, the uninsured and people with individual policies are significantly subsidizing the care of those with employer-based insurance plans. A commentary on causes of personal bankruptcy in America reported that the most common was medical expenses.5,6 Most of those affected were working people who had health insurance at the time of their illness. Only a quarter of those without insurance are jobless. Half are employed, with a distressing one-quarter of the uninsured being children. The consequences of being uninsured in the United States bring to mind the lyrics of an old song: “If life were something that money could buy, the rich would live and the poor would die.” In 2002 the Institute of Medicine estimated that at least 18,000 adults die annually because of uninsurance.7 These deaths are what fuels my passion in the struggle for a national health insurance program. In 2006 at least 47 million Americans—16% of the population at the time—were without health insurance.8 They have been deprived of their dignity, and we are in danger of losing our dignity as a nation. America is the only major industrialized nation that does not guarantee access to needed care for all its citizens. It is the only advanced country that permits people to become bankrupt over medical expenses and allows people to lose their insurance with a serious illness.
Conclusions Leaders from the organization Physicians for a National Health Program (www.pnhp.org.) have put forth comprehensive proposals for how to bring about a national health insurance plan in this country. The plan is modeled after the best of what works in other industrialized countries such as Canada and Great Britain, while addressing some of the pitfalls that have emerged plus concerns that are uniquely American.9 The components of this optimized national health program include: 1. Universal: Everyone in, nobody out, single risk pool 2. Comprehensive: All needed care, no co-pays or deductibles 3. Single, public payer: One form and point of contact
404 4. No investor-owned health maintenance organizations or hospitals paid by public funds 5. Improved health planning 6. Public accountability for quality and cost with minimal bureaucracy9 These basic components would go a long way to restoring the lost dignity of the people and our country. Although politics would seem to dictate that change would need to be done in an incremental fashion, many believe that for real change to occur, it must come with the same revolutionary mandate as the original Medicare plan in 1965. The Institute of Medicine states: “Between the health care we have and could have lies not just a gap but a chasm. You can't cross a chasm in two jumps.”10
References 1. Woolhandler S, Himmelstein DU. Health reform failure. Boston Globe, Sep 17, 2007. Available at: http://www.boston.com/yourlife/ health/other/articles/2007/09/17/health_reform_failure/. Accessed November 8, 2008.
S. Fenichel 2. General Assembly of the United Nations. The universal declaration of human rights. Art. 25.1. Available at: http://www.un.org/Overview/ rights.html. Accessed November 8, 2008. 3. Centers for Medicare and Medicaid Services. National health expenditure projections 2007-2017. Available at: http://www.cms.hhs.gov/National HealthExpendData/Downloads/proj2007.pdf. Accessed November 8, 2008. 4. Centers for Medicare and Medicaid Data. National health expenditure data. Available at: http://www.cms.hhs.gov/NationalHealthExpend Data/25_NHE_Fact_Sheet.asp#TopOfPage. Accessed November 8, 2008. 5. Himmelstein DU, Warren E, Thorne D, Woolhandler S. Illness and injury as contributors to bankruptcy. Health Aff (Milwood) 2005;suppl. Web exclusives:W5-63-73. Available at: http://content.healthaffairs. org/cgi/reprint/hlthaff.w5.63v1. Accessed November 8, 2008. 6. Woolhandler S, immelstein DU. Competition in a publicly funded health care system. BMJ 2007;335:1126-9. 7. Institute of Medicine. Insuring America’s health: principles and recommendations. Available at: http://books.nap.edu/html/insuring_health/ reportbrief.pdf. January 2004. 8. National Coalition on Health Care. Health insurance costs. Available at: http://www.nchc.org/facts/cost.shtml. Accessed November 8, 2008. 9. Physicians for a National Health Program. Proposal of the Physician’s Working Group for single payer national health insurance. Available at: http://www.pnhp.org/publications/proposal_of_the_physicians_ working_group_for_singlepayer_national_health_insurance.php. Accessed November 8, 2008. 10. Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
The ethics of national health insurance: a personal essay Steven Fenichel, MD ⁎ Atlantic City Medical Center, 2117 Bay Avenue, Ocean City, NJ 08226, USA
Abstract As the number of uninsured and underinsured American citizens increases, there is new interest in developing some sort of national health plan to ensure what many consider a basic right in industrialized countries. The debate is no longer merely between the “socialized medicine” advocates and those who believe the government should stay completely out of health care delivery. Now between those who agree that some sort of national health plan is necessary, there is conflict between the “incrementalists” and the “revolutionists,” who have differing ideas on how to best expand health care access to those without. © 2009 Elsevier Inc. All rights reserved.
Introduction
Background
In June 1976, I graduated from medical school in Ireland. On July 1, I started my internship at Mt. Sinai Hospital in Toronto, Ontario, Canada. On my first day, the Director of Medical Education called me for a short meeting. She presented me with an OHIP card for both my wife and me. I asked her what was an OHIP card? She proudly stated that OHIP stands for Ontario Health Insurance Program. I asked what does it do? She responded, “Any doctor or hospital anywhere in Canada is there for you if there is a need. If medicine is prescribed it is covered. If you have a mental problem, an addiction, dental needs, require eyeglasses… All you need do is present your OHIP card.” The answer still resonates within me 32 years later.
My years of training at one of America's premier inner city teaching hospitals, Cook County, as well as my years teaching residents and caring for mainly indigent patients at the Atlantic City Medical Center, have sensitized me to the inequities for the poor when it comes to health care. In addition, hearing the horror stories from family, friends, and neighbors concerning their experiences convinces me that real “Homeland Security” is “Health Care For All.” Several questions come immediately to mind when facing the early 21st century version of American medicine. What dermatology resources are available for the working poor? Poorly funded inner city hospitals often attract the most caring, passionate physicians committed to providing the best care for our poorest citizens. These include academicians and their residents, who work with the limited resources of publicly funded hospitals to care for “everybody and anybody.” Outside the dermatology clinics of these institutions, there are ever fewer private offices that will see Medicaid patients, let alone “charity” patients who have no insurance of any kind and cannot afford any payment. It is
⁎ Fax: +1 609 391 1806. E-mail address: [email protected]. 0738-081X/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.clindermatol.2009.02.014
402 understandable that there are limits to the number of patients that a dermatologist in private practice may see for severely reduced fees and keep the doors open, but rather than blame dermatologists for their lack of charity, we should look at how to improve a system that seems to be designed to send our less affluent patients begging. How does one access medication assistance programs for more expensive medications? Even a $10 generic antihistamine is beyond the financial reach of many indigent care and Medicaid patients. These patients are assisted by social workers, who spend their days trying to help patients obtain prescribed medicines. In the Cook County and Atlantic City Clinics, perish the thought of prescribing more sophisticated and expensive remedies such as biologic modifiers or even tretinoin cream. At the end of most clinic days, the social workers report that most patients leave without their medicines. Many pharmaceutical companies offer humanitarian assistance to obtain some of their newer and more expensive products, and of course, there are always those samples. This is especially important in the university clinics where our future dermatologists are being trained. It is possible to provide a patient with some samples of the latest and greatest topical steroid or retinoid and, after a bit of paperwork, even obtain a biologic therapy for psoriasis. The upside for the pharmaceutical company is that it gets a young physician in training used to thinking of its product as a first-line therapy. The upside for the patient who is allowed to use medications he or she cannot afford is all too often temporary: Eventually the samples stop coming, and the new dermatologist has to figure out another way to treat the patient. Even availability of high-cost therapies such as the biologics becomes more restricted once the big marketing campaign has drawn down. Perhaps a system where all necessary medications are covered would be better for all parties in this game. How does an uninsured patient get standard of practice surgery for a large periocular basal cell cancer? In years past, I cajoled, pleaded, and sometimes pestered plastic surgery colleagues into accepting an uninsured or Medicaid patient. Many of them were older physicians who have since retired. I have given up trying to find younger physicians to fill the void. Getting in line for the limited surgery slots at the university clinic is one option. Regretfully for many patients, the only practical choice is to wait until the lesion is so large and destructive that they become desirable teaching cases for the oculoplastics or otolaryngology program. This may be great for surgical education, but it is a lousy deal for the patient.
Universal coverage Universal coverage, and the possibility of a national health plan, was a political issue in the 2008 election but not as important an issue as it should have been. During the
S. Fenichel Republican primaries and ultimately in the party's campaign platform, the health care issue was hardly addressed, other than to restrict reproductive rights. Since “many a true word is spoken in jest,” satirist Stephen Colbert, in my view, hit the bulls-eye in describing the Republican health plan: It's so simple. Most people who can't afford health insurance are also too poor to owe taxes. But if you give them a deduction from the taxes they don't owe, they can use the money they're not getting back to buy the health care they can't afford. The Democrats were borrowing an idea from President Nixon in using mandates to coerce the people into buying insurance. The significant difference is that Nixon's mandate aimed to force employers to provide coverage for employees. Senator Obama's plan mandated that all parents, rich or poor, must buy insurance for their children. To see how this goal might be accomplished, we can look to the state where it is already up and running, Massachusetts. It is there that the Republican governor, with the support of State House Democrats (and even Senator Kennedy) initiated the “Massachusetts Miracle.” Viewed with a critical, objective eye, this “miracle” might be more aptly referred to as “fraud.” To achieve universal coverage, the plan mandated Medicaid for all citizens below 100% of the poverty level, such as a family of four earning less than $20,000 annually. For families at 100% to below 300% of the poverty level, the state was to provide partial subsidies. Above 300% of the poverty level, this family of four must buy health insurance or face severe a financial penalty. This penalty is much higher than violation of child labor laws ($50), domestic assault ($1000), or the illegal sale of a firearm ($500).1 Major problems quickly became obvious, especially for the group promised state subsidies. The uninsured were undercounted by 200,000 citizens. Most uninsured are too poor to afford that which most would consider decent coverage, and the “affordable” policies covered little. There was inadequate funding for promised subsidies, and most important, the administrative costs increased to the point that there were no cost savings. Clearly taking this model nationally would only result in failure on a larger scale. In my view, health care is an essential human right. Article 25 of the United Nations 1948 Universal Declaration of Human Rights states: Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or lack of livelihood in circumstances beyond his control.2 More succinctly, Dr Martin Luther King stated, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” But here in America, far from being a human right health care is treated more like a marketplace commodity.
The ethics of national health insurance: a personal essay In talks that I do on the subject of national health care, I ask my audience two questions: “What is America's health care ‘system'?” and “How much does it cost?” No one has been able to answer the first question. The second question is easier. Every February the national health expenditure figures compiled by government actuaries for the previous year are published in the journal Health Affairs. In February 2007, the total health care expenditures of the United States for the year 2006 amounted to $2.26 trillion!3 The actuaries project this amount will nearly double within 10 years to $4.132 trillion. This works out to nearly $21,000/yearly premium/individual. The annual premium for a family of four under this health insurance “plan” would cost $84,000. The other part of this expenditure that is not widely known is that 60% of this $2.26 trillion are public tax dollars. The American taxpayer is already more then half-way to funding a national health insurance plan without even knowing it. The Canadian system was robust in 1976 when I received the OHIP card, as judged by three criteria derived from studies at the Wharton School of Business: quality, access, and cost containment. Canada spends 10% of its gross domestic product to fund its entire health system, which is funded mainly by a progressive income tax in which those who make the most pay a greater share (up to 1.2% of the family income) for the national health plan. What they get from this covers all residents and citizens equally. America spends 16% of its gross domestic product for health care, and this is expected to approach 20% within the decade.4 What America gets for this massive spending is in stark contrast to Canada: 47 million uninsured people and many personal bankruptcies caused by bills for health care! These events are not occurring without pressure on and from the business community. In pursuit of the lowest employee insurance costs, employers are shifting more health care costs to their employees in the form of increased co-pays and deductibles. This is euphemistically referred to as increasing employee “personal responsibility.” Another aspect of the regressive American “system” is seen when an emergency arises. Imagine a motorist without health insurance is involved in a car crash with someone who has health insurance. Suppose that the injuries are identical for both parties, consisting of multiple broken bones and chest tubes to treat pneumothorax. After 5 days, both patients are discharged. In 10 days the uninsured patient gets a bill for $50,000. In 2 weeks the insured driver gets his explanation of benefits from the insurance company. His company approved $12,000 of his $50,000 bill. They agreed to pay $10,000 leaving the patient responsible for $2000. As luck would have it, the driver had a secondary insurance policy that was billed. The secondary policy paid $1500, and the patient was ultimately responsible for $500. This could be viewed a good or bad result, depending on the patient's financial status. The most important fact to recognize in this vignette is that the primary insurance company had a contract with
403 the hospital allowing it to pay 20 cents on the dollar! It is only the uninsured and wealthy foreigners who are charged “full freight” for their health care encounters. This practice of jacking up prices so they can be discounted for the participating insurance companies is known as “charge inflation.” The largest subsidy to the insured comes through the employers' tax write-off for employee health insurance. This federal subsidy is about 10% of total health care spending. Nationally, this subsidy in 2006 amounted to nearly $226 billion. Because everyone, including the uninsured, must pay their income taxes; their money helps pay for employer-based plans. And so once again, the uninsured and people with individual policies are significantly subsidizing the care of those with employer-based insurance plans. A commentary on causes of personal bankruptcy in America reported that the most common was medical expenses.5,6 Most of those affected were working people who had health insurance at the time of their illness. Only a quarter of those without insurance are jobless. Half are employed, with a distressing one-quarter of the uninsured being children. The consequences of being uninsured in the United States bring to mind the lyrics of an old song: “If life were something that money could buy, the rich would live and the poor would die.” In 2002 the Institute of Medicine estimated that at least 18,000 adults die annually because of uninsurance.7 These deaths are what fuels my passion in the struggle for a national health insurance program. In 2006 at least 47 million Americans—16% of the population at the time—were without health insurance.8 They have been deprived of their dignity, and we are in danger of losing our dignity as a nation. America is the only major industrialized nation that does not guarantee access to needed care for all its citizens. It is the only advanced country that permits people to become bankrupt over medical expenses and allows people to lose their insurance with a serious illness.
Conclusions Leaders from the organization Physicians for a National Health Program (www.pnhp.org.) have put forth comprehensive proposals for how to bring about a national health insurance plan in this country. The plan is modeled after the best of what works in other industrialized countries such as Canada and Great Britain, while addressing some of the pitfalls that have emerged plus concerns that are uniquely American.9 The components of this optimized national health program include: 1. Universal: Everyone in, nobody out, single risk pool 2. Comprehensive: All needed care, no co-pays or deductibles 3. Single, public payer: One form and point of contact
404 4. No investor-owned health maintenance organizations or hospitals paid by public funds 5. Improved health planning 6. Public accountability for quality and cost with minimal bureaucracy9 These basic components would go a long way to restoring the lost dignity of the people and our country. Although politics would seem to dictate that change would need to be done in an incremental fashion, many believe that for real change to occur, it must come with the same revolutionary mandate as the original Medicare plan in 1965. The Institute of Medicine states: “Between the health care we have and could have lies not just a gap but a chasm. You can't cross a chasm in two jumps.”10
References 1. Woolhandler S, Himmelstein DU. Health reform failure. Boston Globe, Sep 17, 2007. Available at: http://www.boston.com/yourlife/ health/other/articles/2007/09/17/health_reform_failure/. Accessed November 8, 2008.
S. Fenichel 2. General Assembly of the United Nations. The universal declaration of human rights. Art. 25.1. Available at: http://www.un.org/Overview/ rights.html. Accessed November 8, 2008. 3. Centers for Medicare and Medicaid Services. National health expenditure projections 2007-2017. Available at: http://www.cms.hhs.gov/National HealthExpendData/Downloads/proj2007.pdf. Accessed November 8, 2008. 4. Centers for Medicare and Medicaid Data. National health expenditure data. Available at: http://www.cms.hhs.gov/NationalHealthExpend Data/25_NHE_Fact_Sheet.asp#TopOfPage. Accessed November 8, 2008. 5. Himmelstein DU, Warren E, Thorne D, Woolhandler S. Illness and injury as contributors to bankruptcy. Health Aff (Milwood) 2005;suppl. Web exclusives:W5-63-73. Available at: http://content.healthaffairs. org/cgi/reprint/hlthaff.w5.63v1. Accessed November 8, 2008. 6. Woolhandler S, immelstein DU. Competition in a publicly funded health care system. BMJ 2007;335:1126-9. 7. Institute of Medicine. Insuring America’s health: principles and recommendations. Available at: http://books.nap.edu/html/insuring_health/ reportbrief.pdf. January 2004. 8. National Coalition on Health Care. Health insurance costs. Available at: http://www.nchc.org/facts/cost.shtml. Accessed November 8, 2008. 9. Physicians for a National Health Program. Proposal of the Physician’s Working Group for single payer national health insurance. Available at: http://www.pnhp.org/publications/proposal_of_the_physicians_ working_group_for_singlepayer_national_health_insurance.php. Accessed November 8, 2008. 10. Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.