The Early Years of Australian Medicare: Universal Health Insurance in the Balance

Universal antiretroviral treatment: the challenge of human resources

Foundation Activities To Improve Health Around The World

Supplement: Vision for U.S. Health Care21 January 2020Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of PhysiciansFREERobert Doherty, BA, Thomas G. Cooney, MD, Ryan D. Mire, MD, Lee S. Engel, MD, and Jason M. Goldman, MD, for the Health and Public Policy Committee and Medical Practice and Quality Committee of the American College of Physicians*Robert Doherty, BAAmerican College of Physicians, Washington, DC (R.D.), Thomas G. Cooney, MDOregon Health & Science University and Portland Veterans Affairs Medical Center, Portland, Oregon (T.G.C.), Ryan D. Mire, MDHeritage Medical Associates, Nashville, Tennessee (R.D.M.), Lee S. Engel, MDLouisiana State University Health Sciences Center, New Orleans, Louisiana (L.S.E.), and Jason M. Goldman, MDPrivate Practice, Coral Springs, Florida (J.M.G.), for the Health and Public Policy Committee and Medical Practice and Quality Committee of the American College of Physicians*Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M19-2411 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Visual Abstract. Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians Download figure Download PowerPoint What would a better health care system for all Americans be like?This is the question that the American College of Physicians (ACP) has been asking of its members since July 2018, when the ACP Board of Regents asked ACP's Health and Public Policy Committee and Medical Practice and Quality Committee to "develop a new vision for the future of health care policy," to examine ways to achieve universal coverage with improved access to care, reduce per capita health care costs and the rate of growth in spending, reform clinician compensation, and reduce the complexity of our health care system.To develop this vision and recommend ways to realize it, ACP considered evidence on the effectiveness of health care in the United States and other countries; solicited input from U.S-based members and ACP's policy committees; adopted draft recommendations for review by ACP's regents, governors, committees, and council members; finalized recommendations in response to this feedback; and submitted the recommendations for approval by the ACP Board of Regents. On 2 November 2019, the Board of Regents approved this call to action and 3 companion papers on coverage and cost of care (1), health care delivery and payment system reforms (2), and reducing barriers to care and addressing social determinants of health (3).Why Does the United States Need a Better Health Care System?In developing its new vision for health care, ACP focused on 4 questions:1. Why do so many Americans lack coverage for the care they need?2. Why is U.S. health care so expensive and therefore unaffordable for many?3. What barriers to health care, in addition to coverage and cost, do patients face?4. How do delivery and physician payment systems affect costs, access, quality, and equity?As detailed in the accompanying position papers, there is a clear case that the U.S. health care system requires systematic reform. Too many Americans lack health care coverage. Despite historic gains in coverage with the Affordable Care Act, the United States is the only high-income industrialized nation without universal health coverage (4). Affordability is among the most commonly cited reasons for remaining uninsured (5, 6). The United States spends far more per capita on health care than other wealthy countries do, with nearly 17% of the nation's gross domestic product in 2016 directed to health care (7). Drivers of higher spending include higher prices for health care services, devices, and medications in the United States than in other wealthy countries (8). In addition, administrative costs account for 25% of total U.S. hospital spending (9). Complex medical billing, documentation, and performance reporting requirements for value-based payment initiatives have made the U.S. health care system one of the most administratively burdensome in the world. This burden takes time away from direct patient care, generates billions of dollars of unnecessary administrative costs, and contributes to unprecedented levels of burnout among physicians and other clinicians.Despite high health expenditure, U.S. spending and prices generally do not correlate with better health outcomes. The United States consistently ranks last or near-last in access, administrative efficiency, equity, and health care outcomes (10). Mortality rates are higher in the United States than in comparable countries for most leading causes of death, although the United States does better than its peer countries on deaths from cancer (11). Life expectancy has been decreasing in the United States since 2014 (12). Environmental health hazards, poor nutrition, tobacco use, substance use disorders, prescription drug misuse, suicide, injuries and deaths from firearms, and maternal mortality are reversing progress made over generations of increasing life expectancy. Contributing to suboptimal health outcomes are the many systematic barriers to care that Americans face, including discrimination because of personal characteristics, such as race, ethnicity, religion, language, sex and sexual orientation, gender and gender identity, and country of origin.Underinvestment in primary care in the United States also contributes to suboptimal outcomes. Evidence shows that greater use of primary care is associated with decreased health expenditures, higher patient satisfaction, fewer hospitalizations and emergency department visits, and lower mortality. A Primary Care Collaborative review found that primary care investment is associated with a decrease in ambulatory-sensitive hospitalization and emergency department visits, yet the national average for primary care investment is approximately 5% to 10% of total health care spending, depending on how primary care is defined; it also varies substantially across states. The United States spends much less on primary care than other peer countries. Organisation for Economic Co-operation and Development countries spend an average of 14% on primary care (13). Despite the value that internal medicine specialists and other primary care physicians bring to the health system, the current U.S health care system undervalues primary care and cognitive services (14, 15).Much of the high spending and uneven health outcomes in the United States have been attributed to a fee-for-service payment system (16). Policymakers have sought to move toward value-based payment, but there is little agreement on how best to measure value across health care settings and patients with diverse medical and socioeconomic conditions and preferences. The clinical accuracy, ability of clinicians to act on measures of their performance, and usefulness of quality criteria across programs and payers have come under scrutiny.Finally, health information technology (IT) holds promise to facilitate improvements in care, reduce administrative burdens of practice, and help both physicians and patients communicate and navigate the complexities of the health care system. However, ample evidence shows that health IT is not reaching these goals, but rather adding administrative burden to clinical practice (17, 18).In summary, U.S. health care costs too much; leaves too many behind without affordable coverage; creates incentives that are misaligned with patients' interests; undervalues primary care and public health; spends too much on administration at the expense of patient care; fails to invest and support public health approaches to reduce preventable injuries, deaths, diseases, and suffering; and fosters barriers to care for and discrimination against vulnerable individuals.The ACP's Vision of a Better Health Care System for AllThe ACP believes the United States can, and must, do better and offers the following 10 vision statements for a better health care system for all.1. The American College of Physicians envisions a health care system where everyone has coverage for and access to the care they need, at a cost they and the country can afford.2. The American College of Physicians envisions a health system that ameliorates social factors that contribute to poor and inequitable health (social determinants); overcomes barriers to care for vulnerable and underserved populations; and ensures that no person is discriminated against based on characteristics of personal identity, including but not limited to race, ethnicity, religion, gender or gender identity, sex or sexual orientation, or national origin.3. The American College of Physicians envisions a health care system where payment and delivery systems put the interests of patients first, by supporting physicians and their care teams in delivering high-value and patient-centered care.4. The American College of Physicians envisions a health care system where spending is redirected from unnecessary administrative costs to funding health care coverage and research, public health, and interventions to address social determinants of health.5. The American College of Physicians envisions a health care system where clinicians and hospitals deliver high-value and evidence-based care within available resources, as determined through a process that prioritizes and allocates funding and resources with the engagement of the public and physicians.6. The American College of Physicians envisions a health care system where primary care is supported with a greater investment of resources; where payment levels between complex cognitive care and procedural care are equitable; and where payment systems support the value that internal medicine specialists offer to patients in the diagnosis, treatment, and management of team-based care, from preventive health to complex illness.7. The American College of Physicians envisions a health care system where financial incentives are aligned to achieve better patient outcomes, lower costs, and reduce inequities in health care.8. The American College of Physicians envisions a health care system where patients and physicians are freed of inefficient administrative and billing tasks, documentation requirements are simplified, payments and charges are more transparent and predictable, and delivery systems are redesigned to make it easier for patients to navigate and receive needed care conveniently and effectively.9. The American College of Physicians envisions a health care system where value-based payment programs incentivize collaboration among clinical care team–based members and use only appropriately attributed, evidence-based, and patient-centered measures.10. The American College of Physicians envisions a health care system where health information technologies enhance the patient–physician relationship, facilitate communication across the care continuum, and support improvements in patient care.The accompanying policy papers (1–3) offer specific recommendations, supporting rationales, and evidence on ways the United States can move to achieve ACP's vision.In "Envisioning a Better Health Care System for All: Coverage and Cost of Care" (1), ACP recommends transitioning to a system of universal coverage through either a single payer system, or a public choice to be offered along with regulated private insurance. Although each approach has advantages and disadvantages, either can achieve ACP's vision of a health care system where everyone has coverage for and access to the care they need, at a cost they and the country can afford. The evidence suggests that publicly financed and administered plans have the potential to reduce administrative spending and associated burdens on patients and clinicians compared with private insurers. Other approaches were considered by ACP, including market-based approaches, yet ACP found they would fall short of achieving our vision of affordable coverage and access to care for all. The ACP asserts that under a single payer or public option model, payments to physicians and other health professionals, hospitals, and others delivering health care services must be sufficient to ensure access and not perpetuate existing inequities, including the undervaluation of primary and cognitive care.The ACP proposes that costs be controlled by lowering excessive prices, increasing adoption of global budgets and all-payer rate setting, prioritizing spending and resources, increasing investment in primary care, reducing administrative costs, promoting high-value care, and incorporating comparative effectiveness and cost into clinical guidelines and coverage decisions.In "Envisioning a Better Health Care System for All: Health Care Delivery and Payment Systems" (2), ACP calls for increasing payments for primary and cognitive care services, redefining the role of performance measures to focus on value to patients, eliminating "check-the-box" reporting of measures, and aligning payment incentives with better outcomes and lower costs. The position paper calls for eliminating unnecessary or inefficient administrative requirements, and redesigning health information technology to better meet the needs of clinicians and patients. The ACP concludes there is no one-size-fits-all approach to reforming delivery and payment systems, and a variety of innovative payment and delivery models should be considered, evaluated, and expanded.In "Envisioning a Better Health Care System for All: Reducing Barriers to Care and Addressing Social Determinants of Health" (3), ACP calls for ending discrimination and disparities in access and care based on personal characteristics; correcting workforce shortages, including the undersupply of primary care physicians; and understanding and ameliorating social determinants of health. This position paper calls for increased efforts to address urgent public health threats, including injuries and deaths from firearms; environmental hazards; climate change; maternal mortality; substance use disorders; and the health risks associated with nicotine, tobacco use, and electronic nicotine delivery systems.These are just a partial summary of the recommendations in the 3 position papers; considered together, they offer a comprehensive and interconnected set of policies to guide the way to a better a health care system for all. We urge readers of this call to action to review the 3 papers for a complete understanding of ACP's recommendations and the evidence in support of them.Where Do We Go From Here?The ACP believes that our recommendations, if adopted, would address many shortcomings in U.S. health care, but acknowledges that the recommendations do not address every area of needed improvement. In some cases, more research is needed for effective policy development. Because both are needed, the recommendations aim to balance the imperative for transformational changes with improvements in the current system.The ACP is committed to ensuring that the patient's voice is paramount in creating a health care system that better meets their needs. The ACP also believes that physicians are uniquely trusted and qualified to offer solutions to the problems in U.S. health care.We hope that those who challenge ACP's recommendations will offer their own thoughtful alternative solutions rather than just opposing ours.The ACP rejects the view that the status quo is acceptable, or that it is too politically difficult to achieve needed change. Dr. Atul Gawande wrote, "Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try" (19). By articulating a new vision for health care, ACP is showing a willingness to try to achieve a better U.S. health care system for all. We urge others to join us.

Ensuring America's Health: The Public Creation of the Corporate Health Care SystemRemaking the American Patient: How Madison Avenue and Modern Medicine Turned Patients into Consumers

Photo by Tingey Injury Law Firm on Unsplash
 ABSTRACT
 The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the context of a commitment to publicly funded, universal healthcare coverage.
 INTRODUCTION
 Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice.
 ANALYSIS
 l. Causes of Disease
 If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[1] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many.
 The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[2] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes.
 ll. Alcohol-Related End-Stage Liver Disease
 One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[3] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[4] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[5] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[6]
 In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[7] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[8] In democratic societies, one must take into consideration community morals and values.[9] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[10]
 lll. The Liberal-Egalitarian Proposal
 One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[11] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. 
 The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[12] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[13] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach.
 An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[14]
 Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors.
 lV. Moral and Social Arguments Against the Liberal-Egalitarian Position
 Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[15] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise.
 Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. 
 Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous.
 V. Libertarian Arguments Against the Liberal-Egalitarian Model
 a. State Intrusiveness as Counter to the Liberal-Egalitarian Model
 Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[16] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[17] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[18] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[19]
 The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable.
 b. Fairness
 Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[20] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[21]
 The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. 
 Vl. Universal Coverage
 Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[22] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[23] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[24] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. 
 Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. 
 Vll. Proposed Solution
 Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. 
 An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay.
 CONCLUSION
 The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. 
 -
 [1] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421
 [2] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032
 [3] Moss, p. 1295-1298.
 [4] Moss, p. 1296.
 [5] Moss, p. 1295-1298.
 [6] Moss, p. 1295-1298.
 [7] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033
 [8] Cohen, p. 1299-1301.
 [9] Moss, p. 1297.
 [10] Cohen, p. 1300.
 [11] Cappelen, p. 478-480.
 [12] Cappalen, p. 478-480.
 [13] Cappelen, p.479.
 [14] Cappelen, p. 479.
 [15] Cappelen, p. 479
 [16] Cohen, p. 1301.
 [17] Cappelen, p. 478.
 [18] Cohen, p. 1299-1301.
 [19] Cohen, p. 1301.
 [20] Cappelen, p. 476-480.
 [21] Cappelen, p. 476-480.
 [22] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013
 [23] Kawachi, p. 18-33.
 [24] Kawachi, p. 18-33.

Covering the Uninsured as a Quality Improvement Strategy

Medical professionalism in the new millennium: a physician charter.

The future of health professions education: Emerging trends in the United States.

Combat Stress Management and Resilience: Adapting Department of Defense Combat Lessons Learned to Civilian Healthcare during the COVID-19 Pandemic.

Our health care system is plagued by four overriding deficiencies: lack of universal coverage, high costs, inadequate chronic illness prevention and management, and deficient public health preparedness. An inadequate information technology infrastructure and suboptimal quality of care are aspects of one or more of these four challenges. As a result of these shortcomings, the American people are actually less healthy than our counterparts in developed nations around the world. This travesty saps our potential as individuals and as a country. Lost productivity associated with having 47 million uninsured people costs up to $205 billion per year. Accordingly, I have proposed a comprehensive plan for health care reform marked by its inclusiveness and balance. PUTTING UNIVERSAL COVERAGE FIRST Universal coverage forms the predicate of solving many of our health system problems. Without the continuity of access universal coverage promotes, effective chronic disease management that improves health outcomes and generates savings will be much harder to attain. Certainly, disaster preparedness becomes dramatically more difficult while large pockets of uncompensated care and reliance on hospital emergency rooms remain significant characteristics of American health care. My health care plan provides for unequivocal universal health care coverage through universal responsibility. Americans will be able to get their private insurance through a health insurance marketplace called Universal HealthMart. Modeled after the Federal Employees Health Benefits Plan, Universal HealthMart will provide Americans with the same benefits as every Member of Congress. Insurance company discrimination based on condition will be ended. Every employer and individual will be given the chance to go to Universal HealthMart to purchase high-quality, affordable health care or, if they wish, keep their existing insurance arrangements. If a person is unable to pay for insurance or cover the entire cost, their costs will be subsidized on a sliding scale based on income. Business contributions will also be based on ability to pay. Every American with an income below 100 percent of the Federal Poverty Level will become eligible for Medicaid while changes in the federal match will assure that states are held harmless for this expansion. My plan is the only plan to provide for automatic enrollment and a defined timeline to implement universal coverage. Coverage will occur through direct enrollment as people choose their plans or automatically when people file their tax returns, complete W-4's, or show up for health care with a provider. Through the process of automatic coverage and enrollment, universal coverage is guaranteed. Within 2 years of enactment, all children, young adults to age 29, and adults age 55-64 will be covered. Over the next two years, all remaining adults between 30-54 will be enrolled. MAKING HEALTH CARE MORE AFFORDABLE My plan will make healthcare more affordable because health insurance premiums will be based on ability to pay. In addition, my health care plan will reduce costs throughout the system, especially administrative costs. First, as more and more Americans participate in the marketplace, the agency contracting with health plans on their behalf gains increasing leverage to require sensible efficiencies and price accountability. Second, according to McKinsey Global Institute, medical underwriting and marketing costs alone account for $64 billion in excess insurance company expenses. My plan eliminates insurance company discrimination based on condition, while marketing will be consolidated and streamlined. It explicitly redirects premium dollars to prevention and management of chronic illness, the effects of which are discussed more fully below. IMPROVING CHRONIC ILLNESS MANAGEMENT Chronic illness accounts for 74 percent of private health insurance medical spending and 96 percent of Medicare spending. …

The American health care system is in crisis, and now is the time to build a movement for universal health care. Although the United States is the world’s wealthiest nation and spends more than twice as much per capita on health care as its economic competitors, the World Health Organization ranks the United States 37th in overall quality of health care. We have more than 40 million people who are without insurance and at least half that number who are underinsured or insecurely insured, with fatal consequences: more than 18 000 Americans die each year because they have no health insurance. Unlike every other industrialized nation, we do not have universal health care. Other countries pay less for their health care systems, while covering everyone. How can we create a health care system that provides accessible, affordable, and high-quality health care for all Americans? As a start, 2 years ago I founded the Congressional Universal Health Care Task Force. At that time we introduced House Concurrent Resolution 99, so far signed by 95 representatives, which commits Congress to passing universal health care legislation by 2004. I receive many requests from my colleagues to sign on to incremental health care proposals, most of which provide quick fixes to a fundamentally flawed health care system: bills to increase the number of nurses, bills to expand Medicare here, Medicaid there—without offering the comprehensive systemic reform we need. We need a fresh approach: we must take the for-profit insurance companies out of the health care system. I will soon introduce a national health insurance bill that would create a greatly improved and expanded Medicare for All program. Under this plan, every US resident would have a national health insurance card; would receive all medically necessary services, including prescription drugs and long-term care; have no co-payments or deductibles; and see the doctor of his or her choice. I have worked closely on this bill with Dr Marcia Angell, former editor of the New England Journal of Medicine, and with Physicians for a National Health Program. The author speaks at a health care reform rally. Photo courtesy of Corey Weinstein, MD, CCHP. Medicare has a 2% to 3% administrative overhead rate, whereas for-profit health maintenance organizations (HMOs) and insurance companies have an overhead of between 20% and 30%—to cover the costs of stockholder dividends, lobbyists, huge executive salaries, marketing, and wasteful paperwork. In 1991 the Congressional Budget Office concluded that a single-payer system—that is, an improved Medicare for All program—would save approximately $100 billion dollars per year. Economists estimate that this $100 billion could provide coverage for all of the uninsured and substantially help the underinsured. Every other country in the industrialized world has adopted a not-for-profit health care system because they realized that for-profit systems were too costly, complex, unfair, bureaucratic, and inefficient—bad for the people and bad for the economy. To achieve a publicly financed and publicly administered universal health care program in the United States, we will need to build a broad-based movement that cuts across party lines so that the voices of the underinsured and insecurely insured middle class, as well as the uninsured and the poor, will be heard on Capitol Hill.

Arbitration in Medical Cases in Ukraine

An adequate, performing health workforce is vital for improving health service coverage and health outcomes.1 Yet the availability, distribution, capacity and performance of human resources for health (HRH) varies widely and many countries have fewer health workers than needed for high coverage of essential health services, according to the World health report 2006.2 Signs of progress are emerging, though; several countries are successfully addressing their problems in the area of HRH, resulting in improvements in health outcomes.3 These gains are, however, vulnerable: shortages of and inequitable access to health workers still thwart many countries’ attempts to achieve the Millennium Development Goals (MDGs) and their efforts to scale up their response against noncommunicable diseases and attain universal health coverage. Universal Health Care (UHC) was defined by the World Health organization in 2005.4 Since then it has gained increased recognition as a framework for embracing various global health priorities. New evidence, policy options and advocacy5 in support of the progressive achievement of UHC have been the focus of the World health report: health systems financing6 and of numerous global health events.7,8 In 2011 the World Health Assembly adopted a resolution on UHC,9 and in 2012 a United Nations General Assembly resolution bolstered political momentum in support of UHC and underscored the need for an “adequate, skilled, well-trained and motivated workforce”.10 In this context ensuring that appropriate HRH strategies and priorities are embedded in the UHC and post-MDG agenda becomes crucial. As health systems progressively broaden their scope to cover noncommunicable diseases and other priorities, health workers will face new demands for more comprehensive and equitable service delivery. The challenge lies in addressing past and present gaps while simultaneously anticipating future actions to strengthen the health workforce as an integral part of health systems. The HRH needs demand renewed attention, strategic intelligence and action. Gaps in health worker distribution, competency, quality, motivation and performance need to be addressed in addition to sheer numbers. Fundamental changes in the way in which health workers are trained, managed, regulated and supported and in the role of the public sector in shaping labour market forces will be necessary. Against this background, the Bulletin will publish a theme issue on HRH and universal health coverage to provide an opportunity to identify the changes in HRH investment, production, deployment and retention required to achieve UHC. Its publication will coincide with the Third Global Forum on Human Resources for Health, to be held in Recife, Brazil, on 10–13 November 2013. The Third Global Forum is convened by the Global Health Workforce Alliance (GHWA) – a multisectoral partnership established in 2006 to spearhead the response to HRH challenges – in conjunction with WHO, the Pan American Health Organization and the Government of Brazil. The First Global Forum (Uganda, 2008) resulted in the development of a global HRH roadmap;11 at the Second Global Forum (Thailand, 2011), countries and stakeholders reconvened to review progress and renew their commitments towards increased investment, sustained leadership and the adoption of effective HRH policies. The Third Global Forum will provide an opportunity to update the HRH agenda, to make it more relevant to the current global health policy discourse, including the focus on achieving the health MDGs, the objective of UHC and the emerging debate on the post-2015 agenda. Additionally, countries and HRH stakeholders will be invited to explicitly commit to HRH actions as the basis for an inclusive accountability framework. The Third Global Forum’s programme will position health workforce development as a critical requirement for effective UHC and will be designed around one overarching theme – “human resources for health: foundation for universal health coverage and the post-2015 development agenda” – as well as five sub-themes and their corresponding tracks: (i) leadership, partnerships and accountability for HRH development; (ii) impact-driven HRH investments towards UHC; (iii) a supportive HRH legal and regulatory landscape for UHC; (iv) empowerment of health workers by overcoming policy, social and cultural barriers; (v) the harnessing of HRH innovation and research through new management models and technologies.12 To provide a solid evidence base and background to the Third Global Forum’s proceedings, the theme issue will feature commissioned as well as independently submitted articles that will set the scene for and generate innovative thinking on HRH for UHC. GHWA and WHO welcome contributions on the Forum’s general theme, five sub-themes and tracks, especially those emphasizing aspects of HRH directly related to achieving UHC. Submission of relevant country experiences is particularly encouraged. The deadline for submissions is 10 March 2013. Manuscripts should respect the Bulletin’s Guidelines for contributors (available at: http://submit.bwho.org) and mention this call for papers in the cover letter. All submissions will be reviewed by peers.

Despite recent international efforts to scale-up antiretroviral treatment (ART), more than 5 million people needing ART in low- and middle-income countries (LMIC) do not receive it. Limited human resources to treat HIV/AIDS (HRHA) are one of the main constraints to achieving universal ART coverage. We model the gap between needed and available HRHA to quantify the challenge of achieving and sustaining universal ART coverage by 2017. We estimate the HRHA gap in LMIC using recently published estimates of ART coverage, HIV incidence, health-worker emigration rates, mortality rates of people needing ART, and numbers of HRHA needed to treat 1000 ART patients (based on review studies, 2006). We project the HRHA gap in 10 years (2017) using a simple discrete-time model with a health worker pool replenished through education and depleted through emigration/death; a population needing ART replenished with a given HIV incidence rate; and higher survival rates for treated populations. We analyze the effects of varying assumptions about HRHA inflows and outflows and the evolution of the HIV pandemic in three different regional base cases (sub-Saharan Africa, non-sub-Saharan African LMIC, and South Africa). Current ART coverage for LMIC is around 28%-32% and, other things equal, will drop to 16%-19% by 2017 with constant current HRHA production rates. A naive model, ignoring the increased survival probability resulting from ART, suggests that approximately the current number of HRHA in ART services needs to be added every year for the next ten years to achieve universal coverage by 2017. In a model accounting for increased survival of treated patients, outcomes vary by region; sub-Saharan Africa requires two times, non-sub-Saharan African LMIC require 1.5 times and South Africa requires more than three times their respective current HRHA population to be added every year for the next 10 years to achieve universal coverage by 2017. Even if achieved by 2017, sustaining universal coverage requires further HRHA increases until the system reaches steady state. ART coverage is sensitive to HRHA inflow and emigration. Our model quantifies the challenge of closing the HRHA gap in LMIC. It shows that strategies to achieve universal ART coverage must account for feedback due to higher survival probabilities of people receiving ART. It suggests that universal ART coverage is unlikely to be achieved and sustained with increased HRHA inflows alone, but will require decreased HRHA outflows, substantially reduced HIV incidence, or changes in the nature or organization of care. Means to decrease HRHA emigration outflows include scholarships for healthcare education that are conditional on the recipient delivering ART in a country with high ART need for a number of years, training health workers who are not internationally mobile, or changing recruitment policies in countries receiving health workers from the developing world. Effective organizational changes include those that reduce the number of HRHA required to treat a fixed number of patients. Given the large number of health workers that even optimistic assumptions suggest will be needed in ART services in the coming decades, policymakers must ensure that the flow of workers into ART programs does not jeopardize the provision of other important health services.

序章 脳神経外科最先端治療・ガンマナイフの全貌（ガンマナイフの基礎と原理；ガンマナイフの現状と適応できる疾患 ほか） 第１章 ちょっと気になる頭痛の症状（慢性的に頭が重く痛い—脳深部巨大転移性脳腫瘍；脈打つような頭痛—未破裂脳動静脈奇形 ほか） 第２章 ちょっと気になる目の症状（急に目がみえづらくなった—転移性網膜腫瘍；徐々に視野が欠けてきた—非機能性下垂体腺腫 ほか） 第３章 ちょっと気になる顔の症状（瞬発的な顔の激痛、歯の激痛—三叉神経痛；口元がゆるむ、顔に力が入らない—顔面神経腫瘍 ほか） 第４章 ちょっと気になるよくある頭の症状（めまい—小さな聴神経腫瘍；耳鳴り—大きな聴神経腫瘍 ほか）