By Jeffrey Barg

Published October 1998

• React to this article in the Discussion Forum.

PND: In the American College of Physicians-American Society of Internal Medicine policy paper titled "Access to Health Care for All Americans" it is asserted that the failure of our public and private systems to provide health care coverage for all remains the most critical health challenge facing the nation. Could you explain why ACP-ASIM believes that this is so?

HS: The ACP-ASIM feels that all other health challenges such as trying to reduce the cost of care or improving the quality of care won’t really be of much avail unless those advances are open to all people regardless of their circumstances. We feel that work on improving access to care for all Americans just has to be the first priority. Not incidentally, it’s also going to be very difficult to achieve, which also makes it critical we get started.

PND: A recent article published in Annals of Internal Medicine titled "Social Conditions and Self-Management Are More Powerful Determinants of Health Than Access to Care" seems to take issue with this point of view. What’s your opinion of this argument?

HS: I felt that Dr. Frank, who is the editorialist on these two articles, got it right when he basically said that these are two complimentary approaches to making sure that people have all the advantages of our health care system. What Dr. Pincus said was that even when people have access to care, there are other factors such as education which are very important are powerful determinants of health outcomes. And he calls for much more effort to try to help people live smart, aim for healthy lifestyles and learn how to use valuable knowledge in a way that changes their lives. I agree with that. In many studies dating back 25 years, the most powerful determinant of mortality has been educational status, and, when taking into account access to health care, the Pincus argument is one that in fact has a long and rich history. I think he implies that people who have better living conditions, nutrition, environmental sanitation and especially education will be able to achieve good health outcomes even without access to health care. For people whom those sort of entitlements aren’t enough to insure good health, they’re going to need to talk to a physician, and we physicians need to be prepared to help them to use their education and their living circumstances to achieve the best possible outcomes.

PND: What is the ACP-ASIM program for expanding access?

HS: The College has been a strong proponent of access to health care. Perhaps six months before the Clinton administration tackled the problem of improving access to health care, the College came out with a landmark paper describing the characteristics of a health care financing system and health care quality management system that could provide access without greatly expanding the cost of health care. It recognized the need of trying to set a global budget for health care. That was a very radical step and, once you set a global budget for health care, then that creates all kinds of incentives for trying to improve quality and reduce costs and make good use of the resources you have decided to spend on health care.

The College is no longer advocating a global budget because it’s quite clear that the political climate in this country is against a comprehensive approach to health care for all Americans, especially if it would involve increases in taxes, which it probably would. So the College has been focusing much more on trying to seek incremental approaches to health care. The College has supported state and federal expansions of Medicaid. It’s supported the Kennedy-Kassebaum bill, which is also known as the Health Insurance Portability and Accountability Act, and strongly supported the Kennedy-Hatch Bill that expanded access to care for young people. Most patients who don’t have insurance are employed. The general approach the College is favoring is to continue to try to expand Medicaid enrollment, mostly by trying to push access to Medicaid for people who are up to 200 percent of poverty level.

Another approach is to encourage the states to be more flexible in the way they structure acute care services for Medicaid and for the poor and near poor population in order to try to get more efficiency and therefore better use of funds. The College is also supporting efforts to try to improve the systems for workers who are between jobs. This is a plan that has not provided as much help as people hoped that it would and the college is trying to come up with ways to make this legislation more effective for more people who need it. These aren’t particularly exciting or dramatic proposals and they involve working in the engine room of program design. But, taken as a group, they represent ways in which access can be improved without raising taxes and therefore a way that would be politically acceptable to Congress.

PND: How have these proposals been received in Congress?

HS: Congress has got a lot on its mind right now and ACP-ASIM has been committed to raising the issue of access to health care whenever it has the opportunity to speak with members of Congress or their staff. Frankly, we haven’t gotten much encouragement. Some people are more polite than others in telling us this isn’t a good time to be bringing up this topic, but the bottom line seems to be the same whether we’re talking to people who historically have had a commitment to expanding access to health care or to people for whom this has not been a priority. As a country we really have to look inward and ask ourselves why it is that we can be in the middle of unprecedented prosperity and yet the people who are receiving the bulk of the benefits from our bustling economy are not interested in sharing their good fortune with those who are less fortunate. It’s a sad commentary on America at the end of the twentieth century.

PND: What is the scope of the problem?

HS: I think as of late 1997 there were 30 million uninsured adults and 11 million uninsured children.

PND: Do you think that the merger of ACP and ASIM enables you to more effectively advocate for these changes?

HS: Without any question. The merged organization is more effective in advocating for the needs of patients than before. We have an expanded Washington office and the historic record of the ASIM in advocating on Capitol Hill has been really outstanding. When the ASIM was a separate organization they focused more on issues relating to the conditions of medical practice for physicians than on access to care. With the combined organization we have the marvelous skills of the ASIM office combined with the analytic skills of the ACP Washington office, which has historically focused on a patient-oriented legislation. So now we have much stronger advocacy skills to go with our excellent analytic and policy making skills that we had before the merger. It’s a potent combination and it’s the most obvious benefit of the merger so far.

PND: Do you believe access to care will remain as high a priority within the newly merged organization?

HS: So far, the commitment to access to care is as strong as it’s ever been and I expect it will remain a top priority for the College for the indefinite future. This is an absolute gut issue for the ACP-ASIM and I believe it always will be until the problem’s solved.