The archiving and publishing of the introductory remarks and the proceedings of the first plenary session of the Fourth National Conference on Primary Health Care Access (April 2-4, 1993) was made possible, in part, through the generous support of the Michigan State University/Sparrow Hospital Family Medicine Residency Program, Lansing.
John E. Midtling, MD, MS (Moderator): At this time I would like to call on David Satcher to respond to the plenary speakers this morning.
Dr Satcher was previously the Chair of Family Medicine at the Charles R. Drew University of Medicine and Science, the Chair that Doctor Ludlow Creary now holds, and was also Interim Dean there.
From Drew University, Dr Satcher went to Morehouse University where he was Chair of Family Medicine and from there to Meharry Medical College where he now serves as President. He is a member of the Institute of Medicine of the National Academy of Sciences.
He currently chairs the congressionally appointed Council on Graduate Medical Education which recently released its third report to Congress. We will hear a little bit more about that later this morning.
So, I would like to call on David to make a few comments.
Satcher: Thank you very much. I will be brief since I am speaking in the next session and will get a chance to make all the points I want to make.
But I do want to say that I very much enjoyed the panel. I think it was a very good panel – diverse in perspectives and background. I think they made some very important points. Primarily what I am going to do is to raise some questions.
A Mandate for Changing the Health Care System
I don’t think there is any question about the fact that there is, today, perhaps much more so than even three years ago, a national mandate for significant change in health care in this country.
I think that mandate includes universal access. It certainly includes cost containment and areas dealing with the monitoring of quality.
Therefore, I think the real issue is how do we get there from here. I question whether it is not too early to judge where the [Clinton Administration] task force is going short of those three which I consider to be national mandates.
It is also, I think, fair to say that whatever comes out of the task force may well represent a transition strategy as opposed to a final solution.
One way of looking at this, of course, is to say that there are several different approaches that we can take. One is that we can just admit and say that it is going to cost more money to have universal access, for example, and, therefore, we should not feel that 14% of the Gross National Product is too much for us to spend for health care and that we should raise the level a little higher.
That’s one approach. That probably would not be acceptable.
Another way, of course, is to say that we want to provide health care for everybody but that would mean that everybody would be limited in terms of what would be available such as the Oregon plan. So we would agree to ration health care but to include everybody under the umbrella.
Of course, the other way is to look at the efficiency of the health care system as through managed competition or through a single payer system. Since we have those various options in front of us, the final outcome of this, I think, is still not clear in terms of what kind of proposal President Clinton will present to Congress and certainly what will come out of Congress.
We have to remember that Congress has about 80 health care reform proposals on the table right now that have already been presented to Congress in some detail, including, I believe, one proposal sponsored by 50 people in the House for a single payer system. So, I think it is a long way from here to where we are finally end up in terms of health care reform.
The Employer Mandate
One point I want to raise about managed competition but before I say that another issue raised has to do with employer mandate and, of course, what happened in California when that issue was put on the ballot.
The employer mandate has been included by President Clinton during his campaign as a major part of his strategy. One question about employer mandate, of course, is how would the public respond if employer mandate was put into the context of a different system than the people in the State of California were looking at when they voted.
If, indeed, employer mandate was put into context of a system that had real potential for significant cost savings. That, of course, is the basic argument of those who push managed competition.
Capping Tax Breaks for Employer-funded Health Benefits
Despite the various news bites, I think that it is probably too early to write-off the capping of tax breaks for health care employer funded health care benefits. I still believe it is too early to say that that will not be a part of the final package, either as presented by President Clinton or as approved by Congress.
I agree certainly with Doctor Kevin Grumbach that it is not clear where or how we will end up in this issue of health care reform. It seems to be clear that there is a national mandate for significant change, not just minor change, but significant change that would impact universal access, significant cost containment, and some kind of system of quality control.
As far as A. J. Henley is concern, let me confess that we have a history. A. J. participated in Meharry’s national conference on health care reform this past year. After that, I ended up going to Philadelphia and visiting with him. Then he sent two of his people to Nashville to visit us as we attempt to deal with the challenges and opportunities of managed care for the Medicaid population of Tennessee.
So I have some history as far as A. J. Henley is concerned. I have great respect for what he and his organization have done and are doing in a very difficult situation in Philadelphia.
One interesting point that he made which stands out, of course, is that when you look at the providers in his program (I believe 350 are primary care providers and 1725 are specialists), he says even with that, as he puts it, they are making all kinds of money. Or let’s put it another way – saving all kinds of money for the State of Pennsylvania.
It’s very interesting! If, in fact, with that kind of configuration of providers, a clear shortage of primary care providers, they are still saving or making money. Obviously, the question that stands out is what’s happening to the patients and what’s happening to the providers.
At the American Academy of Family Physicians meeting in San Diego, we had a panel discussion on managed care. I remember specifically some of the concerns expressed by providers in places like New Jersey where they felt that both the providers and the patients were getting shafted in a managed care program for Medicaid.
They felt that the programs were promising patients things in order to get them to sign up. So the patients expected things that were not realistic in a managed care program and that the physicians were sort of “left holding the bag.”
I have heard those complaints from various places throughout the country. I have not heard it from the program in Philadelphia. Obviously, you always have to raise the question – What impact is this program having as A.J. implied on the patients and that includes the patients satisfaction. Are they really getting access to health care in the managed care program? Has that access significantly improved over what it was under fee-for-service system? Or are we saving money by limiting access?
That question stands out and it is one that we will have to continue to deal with. I include the provider situation in that because I happen to believe that providers and patients are victims of the present health care system.
I certainly think providers who have been willing to serve in underserved rural and inner city communities have taken a beating in this present health care system in terms of reimbursement and, obviously, the administrative hassles. So I think any solution which we put forth we have to raise the question – What impact does is it having both on providers and the patients?
It is very hard to comment on statements made by Chris Ramsey except to say – again I think he proves to be quite a visionary as he analyzes the present situation and makes projections for the future from looking at it in terms of different paradigms. I think it is true that we are moving toward significant change.
I think what he has done is to paint very clearly the basis that is driving that change for real health care reform in this country. We often compare our present system, of course, with other countries and it is very clear that we probably are not going to end up with a system that is like any other country.
The real question is – Given our history and our values, can we end up with a system that is superior to that in any other country? I think the answer is yes! I think Chris has painted a paradigm for that kind of approach.