clinical innovations, universal coverage, Twenty Clinical Innovations to Build Patient-Doctor Trust: Twentieth and Last in a Series.

Prospects for Universal Coverage

I will end this 20 part series on clinical innovation to build patient-doctor trust by addressing the issue of universal coverage. After a brief interlude of several days, I will resume blogging by publishing a 16 parts series consisting of chapters from an unpublished book of mine addressed to patients, The book was called You and Your Doctor.I

I don't believe single payer coverage from the federal government is in the immediate cards, but universal coverage in a few states may take place over the next two years. The coverage will be very much a trial and error thing, and it will evolve. The states will be the experimental laboratory.

Universal coverage might enhance the patient trust of doctors, since doctors would have less personal skin in the economic game, and patients would worry less about health bills. But this is sheer speculation, since most Americans or medical professionals have no direct experience with universal coverage.

I am familiar with the different mindsets shaping the universal coverage debate. I published Voices of Health Reform (Practice Support Resources, Inc, 2005). In that book, I interviewed 41 national healthcare stakeholders. These stakeholders came from across the ideological spectrum from conservative to liberal.

Any universal proposal gores somebody’s ox or adorns someone’s ideology or digs into someone's pocketbook. In interviews in Voices of Health Reform, conservatives said universal coverage would never happen because Americans deeply distrust government and the bureaucratic baggage that comes with it. Liberals said universal coverage had to happen if America is to have a moral, equitable, and compassionate society. From the interviews, I predicted gridlock would continue for the short term, and adjustments would be made to cut costs.

Short Term Adjustments

Over the short term, these adjustments are occurring. The latest federal data available (2005) shows U.S. health spending increased at the slowest pace in six years at 6.9 percent, the lowest rate since 1999. Prescription drugs costs decelerated, down to 5.8 percent, thanks in large part to drops in Medicaid drug costs, which rose only 2.8 percent. By far, home health costs grew the fastest, by 11 percent, a sure sign the healthcare industry is decentralizing, with services diffusing out to where patients live. Hospital spending (up 7.9 percent) and physician spending (up 7.0 percent) held steady over previous years.

Breaking Up of Gridlock?

The gridlock I predicted in my book may be breaking up. The Democrats, long champions of government-supported care, control Congress, and Blue States like Massachusetts, Vermont, Maine, and now California have universal plans on the table. I find the California plan, announced yesterday, January 8, which will cost $12 billion, the most interesting. It will cover 6.5 million uninsured, at least one million of whom are illegal aliens. It is a much bigger deal than in Masachusetts, which has only 550,000 uninsured.

I find he California plan intriguing. Why? Becasue many of those in the healthcare paying “buckets” I mentioned in the last blog supposedly will be enlisted to help the California state government pay for the coverage

•Businesses of 10 or more not currently offering coverage would pay 4 percent of their total social security wages to a state fund.

•Doctors would pay 2 percent of their revenues, and hospitals 4 percent of their revenues.

•Health plans would be forbidden from denying coverage because of age and health status and would be compelled to put 85 percent of their profits into health services, rather than marketing or administration. In other words, California plans to spread the economic pain; seeking “by-in” from all health care players, for the good of everyone.

Conventional Wisdom

These various state-based plans feed conventional wishful thinking that national universal coverage will start in the states, and then gain national momentum. This may be. State legislatures are growing weary of diverting costs from education and other state obligations to pay for health care. Employers are showing signs they want to get out of the health coverage business.

Whatever happens, and I am not smart or prescient enough to know what that might be, I believe we’re now about to engage in a great debate about universal coverage leading up to the 2008 election.

If this coverage can strike a reasonable balance between the forces for centralization in D.C, and forces for decentralization in the states, and if universal care can be pulled off by not dramatically increasing state taxes, such care might be achieved in selected Blue States, not yet in the nation as a whole.