It was the leading physician group advocating for publicly funded national
health insurance versus the voice of organized American medicine that has for
decades crusaded against "socialized medicine."
And their divergent visions for health system reform could not be more
starkly at odds: tax credits for the uninsured in a free-market, multipayer
system offering a wide range of health plan options tailored to the
individual, or a Canadian-style, publicly funded, and government-run
Those two visions clashed when psychiatrist Jeremy Lazarus, M.D., speaking
for the AMA, countered Steffie Wool-handler, M.D., co-founder of Physicians
for a National Health Program, in a debate sponsored by the American Medical
Student Association in Washington, D.C., in March.
Physicians for a National Health Program "is a single-issue
organization advocating a universal, comprehensive single-payer national
health program" and has more than 10,000 members across the United
States, according to its Web site.
Lazarus, a former speaker of the APA Assembly, is speaker of the AMA House
of Delegates and chairs the APA Council on Advocacy and Public Policy.
The two physicians were asked to address the question, "What's it
going to take to adequately address the health care crisis?"
Lazarus outlined the AMA's agenda for covering the uninsured, fixing the
Medicare program, and reforming the medical liability system.
He described the AMA's vision for market and regulatory reform coupled with
tax credits for the uninsured and said the plan would cover nearly all of the
uninsured while preserving the greatest amount of choice for patients.
"First, [we would] establish a system of tax credits so individuals
and families can buy health plans—credits that are large enough to make
health plans affordable... and that individuals can get at the beginning of
the year so they can pay for it up front," he said.
"Second, let individuals and families choose their own health plan
from a variety of options. We advocate incentives for insurance firms to
tailor policies to meet individual needs rather than employer recipes. We
encourage plans to compete on the basis of price and quality as defined by
patients, not the employer or the underwriter.
"Third, we propose reform in the regulatory system to create vibrant,
innovative markets for health insurance. That means replacing the regulations
that now increase cost with regulations that create incentives."
Lazarus reiterated the AMA's longstanding opposition to a government-run,
single-payer system, painting a bleak picture of overregulation and long waits
"In other countries what you see is rationing," he said."
You see patients who can't get into acute care. Patients can't see
specialists. Patients are in lines. Things that people of this country would
want, they are unable to get."
Woolhandler emphasized the enormous administrative waste in America's
privatized and fragmented system and pointed to Canada as a counterpoint:
universal coverage with far less administrative cost.
"When you look at the total spending difference between the U.S. and
Canada, nearly half of that difference is accounted for by excess bureaucracy
in the U.S. system," Woolhandler said. "By eliminating that
bureaucracy, we would have $30 billion a year. That is the money we need to
cover the uninsured and to improve coverage for those who have only partial
She suggested that tax credits amounted to a 10-foot rope for a 40-foot
hole. "Tax credits are too small," she said. "To cover poor
people, you have to pay the entire premium. You can't be paying $1,000 toward
the premium or $3,000 toward a family premium and expecting people to pay
$7,000 out of their own pocket."
Woolhandler added that tax credits would likely discourage employers from
offering health coverage. "Employers like Wal-Mart would say `Gee, tax
credits are available. We don't have to offer even the paltry insurance we now
offer.' So lots of people who are getting insurance through low-income jobs
would find that employer-based coverage disappearing because of the tax
credits. The Congressional Budget Office has done these projections and [it
says] that tax credit programs would cover perhaps 2 million or perhaps 4
million Americans at a cost of $40 billion: huge cost, very few people
Lazarus agreed that tax credits would have to be large enough to provide
coverage for the poor and near poor, but said that the AMA's plan would cover
95 percent of those currently uninsured.
He emphasized that there is little support among the public or among
physicians for another large, government-run social insurance program, and he
pointed to Medicare as an example of all that can go wrong with such a
"We don't have a unified social ethic that says this is the way we
want to go," said Lazarus. "The single-payer system we have,
Medicare, is really in a shambles, and you can see what happens when you have
a publicly run system and what happens to it. It is not nimble. It does not
change. It does not support innovation very well. Although plans are under way
to perhaps make it better, it is very difficult to move the behemoth of one
He added, "Economic historians rarely agree on anything, but all of
them agree price controls have never worked, anywhere at anytime. Clearly they
are not working in Medicare either."
In response to skepticism expressed by one medical student who questioned
whether the AMA could claim any longer to represent most American physicians,
Lazarus said that membership in the organization has stabilized and started to
"The AMA represents every state medical society and every specialty
in this country," he said. "So it represents all physicians in
that way. We think our priorities are clear. Our priorities are in medical
liability reform, fixing Medicare, and covering the uninsured."
A Webcast of the debate, "The AMA vs. PNHP: Showdown for a
Solution," is posted online at<www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=1382>.▪