A set of six interim recommendations for “health care that works for all Americans” has drawn a wide range of comments from more than a hundred organizations and thousands of individuals. Typically, they proposed revisions. Many appeared to share this writer’s assessment of the recommendations as a mixed bag. The recommendations and their varied presentation over time reflect shifting dominance in policy struggles within the Citizens’ Health Care Working Group that developed them.

Here, as issued July 18, 2006, are the interim recommendations in brief:

1)       Guarantee financial protection against very high health care costs.

2)       Support integrated community health networks.

3)       Promote efforts to improve quality of care and efficiency.

4)       Fundamentally restructure the way that palliative care, hospice care and other end-of-life services are financed and provided, so that people living with advanced incurable conditions have increased access to these services in the environment they choose.

5)       It should be public policy that all Americans have affordable health care. All Americans will have access to a set of core health care services. Financial assistance will be available to those who need it.

6)       Define a ‘core’ benefit package for all Americans.

Each recommendation is elaborated further and is accompanied by a rationale and discussion.

Once the group issues its final recommendations on Sept. 27, 2006, the president will have 45 days to respond with a report to Congress commenting on the recommendations and, if he wishes, adding his own recommendations. Each of the five pertinent committees of Congress is then required to hold at least one hearing on the recommendations.

Recommendations 2, 3, and 4 are largely if not entirely sound. In this article, I highlight major deficiencies in recommendations 1, 5, and 6.

Taken together, recommendations 1 (catastrophic cost protection) and 6 (core benefits) would provide catastrophic coverage while falling short of assuring all medically necessary care. The report notes that “[t]here are many ways that universal coverage against high out of pocket medical costs could be designed.” The particular example described envisions achieving this through a mandate to buy coverage in an insurance market that offers various policies differing in size of the deductible but all covering the same set of “core benefits.” The elaboration of recommendation 5 (universal coverage as public policy) calls for making “financial assistance… available to those who need it,” so as to make low-deductible policies affordable by people with low incomes. But the WG’s acceptance of deductibles ignores the fact that, for people with low or moderate incomes, deductibles are an obstacle to getting needed care.

Standing alone, recommendation 5, which calls for public policy to guarantee affordable health care to all Americans, would be an extraordinarily important advance in U.S. policy. Moreover, the group calls assurance of health care “a shared social responsibility,” but then it goes on to say, “…we need to find a way to reconcile contrasting views about the role of the marketplace and government, of competition and planning, and of individual and shared responsibility.” Yet, the discussion includes a tantalizing, unelaborated sentence, “We also recognize that, in addition to new revenues and [savings], there are ways that current funds could be reallocated within the system to pay for health care that works for all Americans.” The group does not link this to recommendation 3, relating to improving efficiency.

The elaboration of recommendation 3 makes mention of reducing fraud and waste in administration and clinical practice. Also mentioned, without elaboration, is use of the federal government’s purchasing power to enhance efficiency. But one searches in vain for reference to administrative saving in a single payer system, unfair pricing of goods and services, or redundant capital investment by competing hospitals.

In the elaboration and discussion of recommendation 3, there is major emphasis on consumer-usable information on prices of medical services. This looks to the inappropriate and widely discredited notion of patient as active participant in a market for medical services.

The interim recommendations as listed above are actually the second version issued by the Citizens' Health Care Working Group.  The first version, issued June 1, 2006, included the same six bare-bones recommendations listed above, but the recommendations numbered 5 and 6 above were numbered 1 and 2, giving primacy to the public policy commitment. Moreover, the list of recommendations was preceded by the statement, “Americans will have access to a set of affordable and appropriate core health services by the year 2012.” The more recent iteration specifies no target date. Sources close to the working group report that the force of public comments about the interim recommendations will lead to several desirable revisions, including restoration of a target date and a higher priority for public policy commitment to affordable health care for all.

The two-year Citizens’ Health Care Working Group process leading to these recommendations was mandated by a provision of the Medicare Modernization Act of 2003. One of the stated purposes was, “…to provide for a nationwide public debate about improving the health care system to provide every American with the ability to obtain quality, affordable health care coverage.” A major mechanism specified for the debate was a series of community meetings, which, according to the statute, were “at a minimum, [to] address the following questions:  (I) What health care benefits and services should be provided?  (II) How does the American public want health care delivered?  (III) How should health care coverage be financed?  (IV) What trade-offs are the American public willing to make in either benefits or financing to ensure access to affordable, high quality health care coverage and services?”  (Public Law 108-173; Accessible at http://www.citizenshealthcare.gov/about/law.php).  More than 50 such community meetings were held in the first five months of 2006 to gather responses to a series of multiple-choice questions.

The directive to make health coverage affordable by identifying benefits that could be traded off appears to have led the working group to recommend that a core benefit package be defined. To portray this as a popular mandate, the group, at community meetings and in online polling, posed a question that presupposed a “defined level of benefits” to be desirable. Justification for the focus on catastrophic coverage was generated similarly, with another question.

Here and there in the report, something breaks through that suggests turmoil within the working group. Clear evidence of the turmoil: in July, pressure from group members ousted the group’s chairman, one of the group’s most conservative members, from his post.

Finally, for recommendations supposedly generated in a bottom-up process, the  document fails to report that, in both the online poll and the community meetings, when asked to choose among multiple options for assuring coverage for all Americans, respondents’ overwhelmingly preferred to create a publicly funded national health plan through which all Americans would get their coverage. (http://www.citizenshealthcare.gov/community/mtng_files/chcwg_cm_prelim_data_0306.pdf )

The entire report is online at http://www.citizenshealthcare.gov/recommendations/interim_recommendations.php#interimrecs. The public’s comments are online at http://www.citizenshealthcare.gov/speak_out/comment.php.  The comment deadline having now passed, the WG’s final recommendations to the president and Congress are expected on Sept. 27, 2006 – in time for the public to quiz Congressional candidates about their stands.

The 14-member WG was appointed by the U.S. Comptroller General (head of the GAO) from among more than 530 applicants. They comprise a diverse group with a broad range of health care perspectives, including patient advocates, clinicians, academicians, health industry administrators, employers and workers. By law, none is an elected official or an employee or representative of an advocacy or industry association. Their profiles are available at http://www.citizenshealthcare.gov/about/members.php.

APHA’s comments on the interim recommendations are at http://www.citizenshealthcare.gov/recommendations/orgs/apha_ircomments.pdf.