Garson 2000

Current Perspective
The US Healthcare System 2010

Problems, Principles, and Potential Solutions
Arthur Garson, Jr, MD, MPH
T en years ago, the US healthcare system was declared

“broken,” and it has not improved. Fixes promised by
managed care have not materialized. Premiums are rising.
the Federal Employees Health Benefits Plan, regional agen-
cies would use quality and cost data to produce catalogs of
approved plans. Private physicians, who could belong to
Hassles for patients and physicians abound. Nearly 45 million multiple plans, would deliver care, and the private health
Americans are uninsured. plans would compete on quality and cost.
Over the next decade, these problems will worsen and new National coverage guidelines, which would rely on public
challenges will arise. Although new technology will increase input and the Agency for Healthcare Research and Quality,
efficiency, the cost of new tests and treatments will outweigh would be based on cost-effectiveness and other criteria. Most
the savings. As physicians get better at treating problems, citizens’ health needs would be covered by the basic plan, but
they will lengthen patients’ lives and increase the number of they could pay extra for supplemental coverage.
people requiring care. As baby boomers age, these new
patients will demand top-quality care “their way.” Problem 3: Restriction in Choice of Health
As costs rise, the status quo will not be acceptable to
employers. Some will eliminate benefits for new hires. Others
Care and Job Opportunities
will get out of the insurance business entirely, contributing Principle 3: Alternative to Employer-Based
some funds to coverage costs but no longer providing Insurance: Individuals Can Choose Their own
coverage themselves. These changes will cause the number of Health Insurance
uninsured citizens to grow. The result will be an increasingly Today’s employer-based insurance system restricts individu-
disenfranchised middle class. They—and employers—will als’ choice of insurance, and many people are locked into jobs
vote for radical change. for fear of losing coverage. My proposal provides options for
In my role as a citizen rather than as the president of the alternatives. (1) Employees could either accept job-based
American College of Cardiology (ACC), I have developed a insurance or ask employers to send their portion of premiums
proposal to transform our healthcare system by the year 2010. to regional agencies that would provide an array of plans.
This proposal outlines 6 problems, 6 principles for addressing Income-adjusted federal tax subsidies would cover the re-
them, and potential solutions. mainder of their premiums; families under 100% of the
poverty line would receive full subsidies. Citizens would then
Problem 1: Uninsured arrange their own insurance the same way they arrange
Principle 1: Universal Coverage automobile insurance. (2) Employers with more than 10
Any viable plan for the future must be based on universal employees could be required to either provide coverage or to
coverage, and the “2010 plan” guarantees every American pay the regional agency for each employee. (3) Employers
enrollment in a basic health plan of his or her choice (not would then get out of the healthcare business entirely, which
necessarily a health maintenance organization). Like automo- would allow them to concentrate on business. They would
bile insurance, healthcare coverage would be required. Fam-
pay the regional agencies the premiums.
ily members could use different plans and change plans
annually. Previously uninsured citizens would receive
income-related payments (probably vouchers) to cover the
Problem 4: Administrative Nightmares for
cost of enrollment in a basic plan. Patients and Physicians
Principle 4: Administrative Simplification: Access
Problem 2: Pure Government System Past the Office, to the Doctor
not Acceptable The 2010 plan simplifies the healthcare system. An electronic
Principle 2: Public-Private Partnership medical record with tight security would incorporate the
and Competition physicians’ dictated (or written) notes into patients’ records.
My proposal represents a public-private mix that Americans The software would also bill plans automatically using a
will prefer to a pure government system. Using the model of fee-for-service system for physicians.
From the American College of Cardiology, Bethesda, Md.

Correspondence to Dr Arthur Garson, Jr, American College of Cardiology, Heart House, 9111 Old Georgetown Rd, Bethesda, MD 20814-1699. E-mail
tgarson@bcm.tmc.edu
(Circulation. 2000;101:2015–2016.)
© 2000 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org
2015
Downloaded from http://circ.ahajournals.org/ at UNIV OF ULSTER AT COLERAINE on May 14, 2015
2016 Circulation April 25, 2000
This proposal also eliminates preapproval requirements. plan, 4 potential sources of revenue could more than cover the
Using ACC/American Heart Association and other evidence- costs; some are more palatable than others. These include the
based guidelines as models (or even using the plan’s own following:
“best practice” protocols), each plan would embed its own
guidelines in patients’ electronic records. Instant feedback 1. Federal and state governments already pay $23.5 billion
would be available. for non-Medicaid services to the uninsured.
Payments to plans would also be simplified. Plans would 2. Even a two-thirds reduction in bad debt and charity care
receive from the regional agencies severity-adjusted premi- (currently spent on the uninsured) would save $17
ums representing the median costs for patients with specific billion.
conditions, as automatically downloaded from the electronic 3. Insurance premiums paid by employers with more than
medical record. “True-up” adjustments would be made each 10 employees that currently do not provide health care
quarter for new patients and patients no longer in the plan. could fund $43.9 billion.
4. Automation, elimination of preapproval requirements,
Problem 5: Quality of Health Care Is not and other innovations could increase billing efficiency
by 50% and could save insurers $27.2 billion, hospitals
Consistently Measured, Reported, Understood, $17 billion, and physicians $6.9 billion.
or Used in Decision-Making
Principle 5: Quality Will Become Increasingly With the 2010 plan, patients would gain guaranteed cov-
Important; Emphasis on erage access, choice, and improved care; those with potential
Patient-Physician Relationship heart disease would particularly benefit from universal cov-
By 2010, patients will be able to create their own personal- erage because they would have access to preventive care.
ized report cards from the Internet; for those who cannot do Businesses could concentrate on business, not benefits. Even
it themselves, a new “quality interpreter” business—similar those contributing toward employees’ coverage for the first
to H & R Block—would flourish. time would benefit thanks to healthier employees. Insurers
In the next 10 years, outcomes for common conditions will would benefit by receiving payments that are based on the
be increasingly similar across plans. As a result, plans would severity of patients’ conditions. Physicians could spend time
compete on the basis of innovations in prevention and care. on patient care rather than administrative tasks.
More important, they will compete on physician-patient How do we get there? We can push for electronic medical
relationships. Quality would be a 2-way street: healthy
records, severity-adjusted premiums, and the collection of
behavior could win patients lower co-payments or premiums.
data for evidence-based medicine; we can also help our
patients recognize true quality. Most important, we can
Problem 6: Financing
acknowledge the need for change in the system. Unless
Principle 6: New Expense for Uninsured Paid by physicians get involved, we will have to live with the choices
Redirecting Current Revenue, New Revenue, and others make for us. We must do something.
Increased Efficiency For more information, visit the ACC Web site at
Guaranteeing basic health care for all will be expensive.
http://www.acc.org
Covering the uninsured would cost an estimated $88.6 billion
in today’s dollars.
Over the next 10 years, a number of possible ways of KEY WORDS: healthcare reform 䡲 healthcare system 䡲 health policy
paying for the uninsured will become apparent. In the 2010 䡲 future of healthcare 䡲 uninsured

The US Healthcare System 2010: Problems, Principles, and Potential Solutions
Arthur Garson, Jr
Circulation. 2000;101:2015-2016
doi: 10.1161/01.CIR.101.16.2015
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2000 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://circ.ahajournals.org/content/101/16/2015
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Current Perspective

The US Healthcare System 2010

T en years ago, the US healthcare system was declared

From the American College of Cardiology, Bethesda, Md.

Downloaded from http://circ.ahajournals.org/ at UNIV OF ULSTER AT COLERAINE on May 14, 2015

Reprints: Information about reprints can be found online at:

Subscriptions: Information about subscribing to Circulation is online at:

Downloaded from http://circ.ahajournals.org/ at UNIV OF ULSTER AT COLERAINE on May 14, 2015

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