The American College of Physicians has for the first time called for legally mandated universal coverage for all U.S. residents and has urged lawmakers to consider a single-payer system as one option for achieving that goal.

In a lengthy analysis and health care reform proposal, the ACP also recommends greater use of cost-control incentives directed at patients, perhaps including greater sharing of costs and more use of health care savings accounts.

The report also recommends a uniform billing system for all services, more primary care training programs, federal support for the medical home model, pay for performance, a universal information technology infrastructure, and greater investment in medical research (Ann. Intern. Med. 2008;148:5575).

Robert Doherty, the ACP's senior vice president for governmental affairs and public policy, and one of the authors of the report, said that the ACP will not pursue specific legislation in the coming year aimed at implementing the recommendations, but hopes to bring health care reform to the forefront of the presidential and congressional elections. However, the college supports provisions in the pending Medicare/State Children's Health Insurance Program (SCHIP) bill that would require Medicare to pay physicians in up to 500 practices around the country for coordinating care through a medical home.

David Karlson, Ph.D., executive director of the Society of General Internal Medicine, said that his organization is in "broad agreement" with the principles outlined by the ACP. "Many SGIM members have been even more favorably disposed to simplified (e.g., single-payer) approaches to health insurance financing, and place an even greater emphasis on physicians avoiding conflicted relationships with industry," he said in an interview.

In advocating for universal coverage, the authors of the report compared the U.S. system with the systems of selected other countries, including those with a single-payer system of universal coverage (Canada, Japan, Taiwan, and the United Kingdom) and those with a "pluralistic" system, in which private and public institutions fund the costs of care for all residents (Australia and New Zealand) and coverage is guaranteed regardless of ability to pay.

Single-payer systems, the report said, are generally more equitable, have lower administrative costs, and have lower per capita health care expenditures than do systems using private health insurance. Single-payer systems also have high levels of patient satisfaction and high performance on measures of quality and access. However, shortages of services as a result of price controls are a risk.

A pluralistic system of universal coverage would "ensure universal access while allowing individuals the freedom to purchase private supplemental coverage. The disadvantages of this system are that it is likely to result in inequalities in coverage and higher administrative costs," according to the report.

Dr. Arnold S. Relman, former editor of the New England Journal of Medicine, said that he found the ACP's recommendations "very disappointing." In his view, a pluralistic system in which nonprofit and for-profit institutions fund care via insurance is essentially no different from the current system. Moreover, the idea that there could be legally guaranteed coverage in such a system is "totally unrealistic," said Dr. Relman, professor emeritus of medicine and of social medicine at Harvard Medical School, Boston.

Dr. James King, president of the American Academy of Family Physicians, said that although insurance company profits share some of the blame for increasing costs, the cost of increasing technology and duplicated procedures (which could be prevented by electronic health records) also are factors.

The AAFP also has issued health care reform recommendations (available at www.aafp.org

In its report, the ACP called for "incentives to encourage patients to be prudent purchasers and to participate in their health care." These incentives could include increased use of "cost sharing," in which patients are required to pay more out-of-pocket costs, as well as more use of health care savings accounts, but should be designed to not deter patients from getting needed care, the report said.

This goal of cost sharing is "a favorite of all the conservative think tanks… but it ain't going to work." Dr. Relman said. "When you're sick, you don't shop around. There are no consumers in the emergency room or in the intensive care unit."

Dr. David Dale, president of the ACP, agreed in an interview that there are times when an acutely ill patient necessarily has a passive role in choosing health care. But the recommendation for greater patient involvement is especially relevant in the context of chronic care, said Dr. Dale, also professor of medicine at the University of Washington, Seattle.

In any case, there is near unanimity that health care costs are out of control. Dr. Harold Sox, editor of the Annals of Internal Medicine, wrote in an editorial accompanying the report, "The country seems headed for an unprecedented fiscal crisis if it can't control the costs of health care" (Ann. Intern. Med. 2008;148:789). He noted that although health care reform is a frequent topic in the nascent presidential election season, the same was true in 1992, and major reforms did not arrive.

The American Academy of Dermatology has not taken a position on this issue, according to an AAD representative.

Internists Call for Health Insurance Mandate