"Universal Coverage and the Presidential Candidates' Health Care Proposals"

I and more than 80 other physicians, public health and medical practitioners, and social policy experts have signed the below letter. It notes the importance of health reform, and it notes why the issue of "individual mandates" has taken on undue importance in the health policy and presidential debate.

I am not the author--just another signatory with the quickest blog. I am, however, proud to be in this group. I think the letter speaks for itself.

The leading Democratic and Republican candidates for president have proposed major changes to our health care system. These proposals are worthy of serious consideration. Rising medical costs threaten our country's long-term fiscal stability. And our failure to provide health insurance to 47 million Americans is cause for shame.

As this year's competitive primary election season builds to a climax, arguments within each party are bound to become heated. As candidates seek a competitive edge, it is natural to magnify small differences. But if the political debate over health reform is to inform Americans about the choices we face, it should be grounded on facts.

The remarkably similar health plans proposed by Senators Clinton and Obama have the potential to reduce the number of uninsured Americans (citizens, permanent residents, and others lawfully present in the U.S.) to two percent or less of the population. Achieving this goal would require full implementation of these plans' subsidies and insurance market reforms, plus robust outreach efforts to get everyone to sign up for coverage.

The necessary outreach will not be easy, and it will be fruitless unless health insurance is made affordable and accessible to all. Some believe that an individual mandate to buy health insurance should be part of this effort; others hold that a mandate would be paternalistic or too onerous for families at the margins of affordability. Regardless of our feelings on this issue, what is clear from the evidence is that mandates alone, without strong incentives to comply and harsh punishments for violation, will have little impact on the number of uninsured Americans.1 Indeed, as the Massachusetts experience illustrates, non-compliance with mandates is a large problem, absent harsh sanctions. There is simply no factual basis for the assertion that an individual mandate, by itself, would result in coverage for 15 million more Americans than would robust efforts to make health care more affordable and accessible.

The inaccurate claim that an individual mandate alone would reduce the ranks of the uninsured by 15 million draws attention away from the challenges we must surmount to make good medical care available to all. These challenges include adequate public subsidies, insurance market reform, outreach to people at the margins of American life, and long-term control of medical costs. Individual mandates may have a role in health care reform, but there is risk of a specious "Mission Accomplished" moment. It is a time for rolling up our sleeves and addressing the hard work required to get everyone care. The central challenge is to make health insurance affordable and accessible, and to reach out to all Americans to help them obtain coverage. Voters should insist that candidates for president address these very real issues.

1 S.A. Glied, J. Hartz, and G. Giorgi, "Consider It Done? The Likely Efficacy Of Mandates For Health Insurance," Health Affairs 26 (2007): 1612-1621.

Signers:

Stuart Altman
Dean and Sol C. Chaikin Professor of National Health Policy
Heller School for Social Policy and Management
Brandeis University

M. Gregg Bloche, MD, JD
Professor of Law
Georgetown University
Non-Resident Senior Fellow
The Brookings Institution
Adjunct Professor
Bloomberg School of Public Health
Johns Hopkins University

Nicholas A. Christakis, MD, PhD, MPH
Professor
Department of Health Care Policy
Harvard Medical School
Department of Sociology
Faculty of Arts and Sciences
Harvard University

David Matchar, MD
Professor of Medicine
Director, Center for Clinical Health Policy Research
Duke University Medical Center

E. Richard Brown, PhD
Professor of Health Policy
UCLA School of Public Health

Henry J. Aaron
Senior Fellow, Economic Studies
The Bruce and Virginia MacLaury Chair
The Brookings Institution
Paul Weiler
Emeritus Professor of Law
Harvard Law School

Elliott S. Fisher, MD, MPH
Professor of Medicine and Community and Family Medicine
Director, Center for Health Policy Research
Dartmouth Institute for Health Policy and Clinical Practice.

Harold Pollack, MPP, PhD
Faculty Chair, Center for Health Administration Studies
Associate Professor
School of Social Service Administration
University of Chicago

Lainie Friedman Ross, MD, PhD
Carolyn and Matthew Bucksbaum Professor of Clinical Ethics
Professor, Departments of Pediatrics, Medicine, and Surgery
Associate Director, MacLean Center for Clinical Medical Ethics
University of Chicago

David Blumenthal, MD, MPP
Director, Institute for Health Policy
Physician, Massachusetts General Hospital
Samuel O. Thier Professor of Medicine
Harvard Medical School
Professor of Health Care Policy
Harvard Medical School

Theodore Marmor, PhD
Professor Emeritus of Public Policy and Management
Professor Emeritus of Political Science
Yale School of Management

Barbara Starfield, MD, MPH
University Distinguished Professor
Johns Hopkins University

Paula Lantz, PhD
Professor and Chair
Department of Health Management and Policy
University of Michigan

Mark Schlesinger, PhD
Professor of Health Policy
Yale University

Nancy L. Keating, MD, MPH
Associate Professor of Medicine and Health Care Policy
Harvard Medical School

Gerald F. Kominski, PhD
Associate Dean for Academic Programs
Professor, Department of Health Services
UCLA School of Public Health

Diane S. Lauderdale
Associate Professor
Department of Health Studies
University of Chicago

David Cutler
Otto Eckstein Professor of Applied Economics
Harvard University

Einer Elhauge
Petrie Professor of Law
Director, Petrie-Flom Center in Health Law Policy
Harvard Law School

Kathleen A Cagney
Associate Professor
Department of Health Studies
University of Chicago

Ronald S. Sullivan Jr.
Clinical Professor of Law
Director, Harvard Criminal Justice Institute
Harvard Law School

Henry J. Steiner
Jeremiah Smith, Jr. Professor Emeritus
Harvard Law School

Martha Minow
Jeremiah Smith, Jr. Professor
Harvard Law School

Jerry Mashaw, PhD
Sterling Professor of Law and Management
Yale University

Laurie Zoloth, PhD
Director, Center for Bioethics, Science and Society
Director, Brady Program in Ethics and Leadership
Professor of Medical Humanities and Bioethics
Feinberg School of Medicine
Northwestern University

Dayna Bowen Matthew
Associate Dean of Academic Affairs
Professor of Law
University of Colorado School of Law

Elizabeth Bartholet
Morris Wasserstein Professor of Law
Faculty Director, Child Advocacy Program
Harvard Law School

Ellen Meara, PhD
Department of Health Care Policy
Harvard Medical School

Donald E. Fry, MD, FACS
Professor Emeritus
Department of Surgery
University of New Mexico School of Medicine

Mark E. Courtney
Ballmer Endowed Chair for Child Well-Being
School of Social Work
University of Washington

Jacqueline Fox
Assistant Professor
School of Law
University of South Carolina

Oliver Oldman
Learned Hand Professor of Law, Emeritus
Harvard Law School

Jane Loewenson
Partner
Nueva Vista Group LLC

Laurence H. Tribe
Carl M. Loeb University Professor
Harvard Law School

Thaddeus Mason Pope, JD, PhD
Visiting Professor, Widener University School of Law
Senior Scholar, Thomas Jefferson University Medical College
Assistant Professor of Law
University of Memphis School of Law

Mervin Shalowitz, MD Visiting Scholar
Kellogg School of Management
Northwestern University

Barbara A. Noah
Associate Professor
Western New England College School of Law

William Pitsenberger
Adjunct Professor, Health Law and Policy
Washburn University School of Law

Philip J. Rosenthal
Professor
Department of Medicine
University of California, San Francisco

Sarah-Anne Schumann, MD
Clinical Associate
Department of Family Medicine
University of Chicago Pritzker School of Medicine
Chicago Family Health Center

Daniel H. Lowenstein, MD
Professor of Neurology
Director, Physician-Scientist Education and Training Programs
University of California, San Francisco

Jonathan Skinner, PhD
Professor
Dartmouth College & Medical School

Robin Henry Dretler MD, FIDSA
President
Infectious Disease Specialists of Atlanta

Laurel Coleman, MD, CMD, FACP
Physician
Augusta, Maine

Ann M Labriola, MD
Associate Professor of Medicine
Division of Infectious Diseases
Department of Medicine
George Washington University Medical Center

Jens Ludwig
Professor of Social Service Administration, Law, and Public Policy
University of Chicago

Norman Daniels
Professor of Ethics and Population Health
Harvard School of Public Health

Donald H. Taylor, Jr. Ph.D.
Assistant Professor of Public Policy
Duke University

Colleen Grogan
Faculty Director, Graduate Program on Health Administration and Policy
Associate Professor
School of Social Service Administration
University of Chicago

Leon Wyszewianski, PhD
Associate Professor
Director, Executive Master's Program
Department of Health Management and Policy
University of Michigan School of Public Health

John Henning Schumann, MD
Section of General Internal Medicine
MacLean Center for Clinical Medical Ethics
Human Rights Program
University of Chicago

Michael Pine
Lecturer in Medicine
University of Chicago

Wade S. Smith, MD, PhD
Professor of Neurology
University of California, San Francisco

Keith W.L. Rafal, MD, MPH
Assistant Clinical Professor
Brown University Medical School

Bob Arnold
Professor of Medicine
Leo H Criep Chair in Patient Care
Chief, Section of Palliative care and Medical Ethics
University of Pittsburgh

James Tulsky, MD
Professor of Medicine and Nursing
Duke University

William M. Altman, JD, MA
Senior Vice President of Strategy and Public Policy
Kindred Healthcare, Inc.

Rebekah E. Gee, MD, MPH
Robert Wood Johnson Clinical Scholar
University of Pennsylvania

Clarissa K. Wittenberg
Health Education Consultant

Jason Block, MD
Physician
Brigham and Women's Hospital

Harlan M. Krumholz, MD SM
Harold H. Hines, Jr. Professor of Medicine
Yale University

S. Claiborne Johnston, MD, PhD
Professor of Neurology and Epidemiology
Director, Stroke Service
University of California, San Francisco

Richard Kronick
Professor
Department of Family and Preventive Medicine
University of California, San Diego

Maggie Czarnogorski, MD
George Washington University
Carl Vogel Center, Medical Director

Howard P. Forman MD, MBA
Professor of Diagnostic Radiology, Management, and Public Health
Lecturer, Economics
Director, Yale MD/MBA Program and Yale MBA for Executives: Leadership In Healthcare
Yale University

William Terry, MD
Brigham and Women's Hospital

Rahul Rajkumar, MD, JD
Physician
Brigham and Women's Hospital

Frederick A Masoudi, MD, MSPH
Associate Professor of Medicine (Cardiology)
Denver Health Medical Center
University

David A. Richardson
Health Care Consultant

Helen Levy, PhD
Research Assistant Professor
University of Michigan

Robert Burt, JD, MA
Professor
Yale Law School

David B. Wilkins
Kirkland & Ellis Professor of Law
Director Program on the Legal Profession
Harvard Law School

Gene Webb, PhD
Manager of Planning
Biological Sciences Division
Pritzker School of Medicine
University of Chicago

Nikhil Wagle, MD
Physician
Brigham and Women's Hospital

Clifford E. Douglas, JD
Executive Director, University of Michigan Tobacco Research Network
Adjunct Lecturer, University of Michigan School of Public Health
Senior Policy Fellow, Michigan Public Health Institute

Thomas G. McGuire
Professor of Health Economics
Department of Health Care Policy
Harvard Medical School

Robert A. Berenson, MD
Senior Fellow
The Urban Institute

Stanley S. Wallack
Professor
Heller School for Social Policy and Management
Brandeis University

Charles J. Ogletree, Jr.
Jesse Climenko Professor of Law,
Harvard Law School

Jon Klein, MD, PhD
James Graham Brown Foundation Endowed Chair in Proteomics
University of Louisville

Sara Rosenbaum
Chair, Department of Health Policy
Harold and Jane Hirsh Professor of Health Law and Policy
Professor of Health Care Sciences
George Washington University

John C. Coates IV
John F. Cogan, Jr. Professor of Law and Economics
Harvard Law School

Peter J. Hammer
Professor of Law
Wayne State University Law School

Meredith B. Rosenthal, PhD
Associate Professor of Health Economics and Policy
Department of Health Policy and Management
Harvard School of Public Health

Barron H. Lerner, MD, PhD
Professor of Medicine and Public Health
Columbia University

Lucian L. Leape, MD Harvard School of Public Health

Kasturi Haldar
Charles E. and Emma H. Morrison Professor
Department of Pathology
Northwestern University

Comments

[splashy]

This couldn't be more wrong:
"The central challenge is to make health insurance affordable and accessible,"

The REAL challenge is to make HEALTH CARE affordable and accessible. Single payer would work just fine.

[ddrew2u]

Imagine a future in which mandates force families to purchase health plans with a $10,000 deductible (the cheapest legal option?) -- okay; they obeyed the law -- but now they end in the emergency room MORE OFTEN because they used up their private doctor visit money on what Obama correctly styles as "home insurance."

Medicare for all ought to be the easiest program in the world to sell: Medicare is the plan most folks happily look forward to relying on when they are older and perhaps much more in need of even critical care -- why in the world should they hesitate to rely on it now while they are young and usually healthy?

[LeftRight]

This is a letter which doesn't say anything. First it says how mandates won't work, and then it says how they can work with tough enforcement and harsh penalties. There are three problems with this:

1) Mandatory insurance without price caps will result in more people living below the effective poverty level (net income minus essential goods and services, leaving not enough, or negative)

2)Tough enforcement will cause an increase in government bureaucracy which will make Homeland Security look like a hiccough. This will negate ANY savings cost over going single payer, and will in fact make us spend many times more for health care per capita than we already do.

3) Harsh penalties. What happens if I'm a father with a family of four, making poverty wages? My job won't provide health care, and I can't buy into any sort of a group plan, so I go out and buy a single plan for my family of four. Since poverty is defined as a family of four making $20,650, and my single family health care plan costs about $12,000 a year, WHERE THE HELL AM I GOING TO LIVE? I know for a fact that after food is bought, there is no money left!

[TheHandyman]

Was I the only one to notice the "without incentives or harsh penalties" statement. I have heard tat Mass fines everyone without health insurance $1,200. If that is the case, if the person had $1,200 they probably would buy health insurance. This is just another scam. It is like just mandatory automobile insurance but the government doen't make it mandatory that it be affordable. The mere fact alone that the Automobile and Health Insurance industry makes the outrageous profits they do should tell us how they overcharge. I wonder why even the People themselves don't get that anytime you put profit into the equation you know it will cost more than it should or that it will not do what it says it will. Anyone who has watched Sicko should by now know that the health insurance industry operates at the minimum care, maximum profit level. The people who wrote this letter and so proudly signed it have said nothing other than that they support more of the same poor service that both health plans by the Democan'tic Party Presidential candidates have put forth. A single payer health care system like medicare is the obvious answer but since the candidates are fronted by big health and big Pharma they sure aren't going to bite the hand that feeds them nor are they going to do the right thing.

Michael Moore outed these people but the prolitariat, having very short memories have forgotten.

[argeec]

Man, it took all those people to say virtually nothing - and with no evidence for their position at all.

[bklynsam]

It seems you've just endorsed Obama's health care plan.

I agree.

[lynnn]

OMG that's a lot of names! That needs to be in a mailer for the campaign!

[BillZBubb]

How about cutting out the middle man and just go single payer like every other advanced nation?