Universal Access To Health Care Research Articles

Acquisition of Chlamydia trachomatis by Young Women During Their First Year of Military Service

To define the acquisition rate of Chlamydia trachomatis among a cohort of young, nonhealth-care seeking, sexually active women with well-defined exposure periods over a 12-month period. The long-term goal is to inform public health practitioners and young women of the risk of reinfection with C. trachomatis and the need for frequent active screening to eliminate asymptomatic infections over time. Young sexually active female Marine Corps recruits (N = 332), serving as "controls" for an intervention to prevent sexually transmitted infections, were screened for C. trachomatis using nucleic acid amplification tests (treated if positive) at entry (T1). They were rescreened and completed self-report behavioral surveys at 4 weeks (T2) and 9 to 12 months (T3) from recruit training. The rate of C. trachomatis acquisition during a contiguous 12-month period. Based on microbiologic laboratory testing alone, the acquisition rate for C. trachomatis was 3.6% (T2) and 9.9% (T3) yielding a total of 13.0%. The self-reported acquisition rate for the period since graduation from recruit training was 8.1% yielding a total acquisition rate of 19.9%. The acquisition rate among this cohort of nonhealth-care seeking young women, who have universal health care access is as high or higher than most clinic-based studies, suggesting the need for increased implementation of active screening in primary, urgent, and nonclinic settings.

Improving Access to Health Care: A Consensus Ethical Framework to Guide Proposals for Reform

As the American system of health care delivery strains under the weight of erratic coverage, inefficiency, and uncertain quality, proposals for how it should be reformed have proliferated. (1) Some proposals focus primarily on improving quality, others on restraining costs; all, directly or indirectly, address access health care. (2) We present a consensus framework for evaluating how well a proposal addresses the issue. While access is affected by a number of factors (geography, distribution of providers, and so on), for this essay we focus primarily on ethical issues in access health care coverage. The framework emerges from the work of the multi-stakeholder Ethical Force Program, which uses a standardized process derived from well-accepted methods for generating consensus on clinical practice guidelines and measuring quality in health care. (3) The program is a collaborative initiative led by the Institute for Ethics at the American Medical Association. It was established in 1997 to improve health care by advancing ethical behavior among all participants. (4) It is motivated by the beliefs that ethical standards are fundamental health care systems that are effective and trusted, that all stakeholders in health care should be accountable for their ethics, and that stakeholders must work together ensure that shared ethical standards are widely promoted, understood, and followed. (5) The program functions as a national quality improvement organization for health care ethics. As such, it produces an array of reports and tools that all stakeholders can use assess and improve the ethical environment of health care. The method by which it produces consensus statements has been described in detail elsewhere. (6) In brief, it runs as follows. An oversight body provides guidance on all programmatic activities. (For a list of the members, see the accompanying box.) The oversight body comprises a diverse group of leaders from all aspects of health care delivery, including clinicians, patients, provider organizations, purchasers, and others. The AMA holds two seats on the oversight body; the Agency for Health Care Research and Quality, the American Hospital Association, The Joint Commission, and the National Committee for Quality Assurance also hold permanent seats. The remaining seats are filled three-year terms by vote of the oversight body, which seeks ensure diverse perspectives and involvement. To determine consensus on recommendations, the oversight body votes on whether members support each recommendation using a one ten scale. A statement is rejected if it fails achieve an average score of greater than seven or if any member gives it a vote of less than three. We used this consensus process come agreement on four core ethical obligations for health system reforms that aim improve access care. We present these obligations with a number of more specific consensus recommendations that follow from taking the four ethical obligations seriously. Access Health Care as an Ethical Issue As the number of Americans without health care coverage continues increase, access care is a major political, economic, and policy problem. Unequal access health care is also an ethical issue. Most Americans understand this: 72 percent think our society should ensure universal access health care, and 60 percent consider it be a moral rather than a strictly political or economic issue. (7) We hold that three core American values are at stake: equality of opportunity, justice, and compassion. Equality of opportunity is essential for each of us fulfill the American promise of life, liberty, and the pursuit of happiness, and personal health is an essential ingredient ensure opportunity. (8) Equality of opportunity is compromised whenever identifiable subpopulations of American society are disproportionately affected by limited access care. For instance, it belies the American ideal that all are created equal when disparities in access care lead consistently poorer health outcomes for specific racial and ethnic groups. …

Good and bad lessons from the United States

The JRSM's readership is mostly UK based, with our second largest readership hailing from the United States of America. Yet the difference in reader numbers between the UK and US is so large that this publication is some way from becoming a transatlantic journal, although when you read this issue you might be forgiven for gathering that impression. The increasing influence of US healthcare and US healthcare organisations on the UK's health system are good reasons to occasionally dip this Journal's pages in the Atlantic. For instance, both of this month's research papers are analyses from across the pond. First, Arch Mainous III and colleagues compare diabetes management in adults between England and the US, a highly topical issue since the English government is planning to offer opportunities in primary care provision to American companies, among others (p. 463). Some early but contentious evidence has suggested that the UK's health systems, systems that offer universal access, might have much to learn from the US and its market-based system. Particularly since advocates and critics of the current reforms in the English health service love to talk of the ‘emerging healthcare market’—which is a good or an evil thing depending on your politics. Mainous III and his fellows (none of whom, disappointingly, have Roman numerals after their names) judge that individuals in the universal access healthcare system have better management of diabetes, as measured by HbA1c and prescription of ACE inhibitors, than those who are uninsured in a market-based system. Indeed, the differences between the uninsured and the insured in the market-based system are also eye-catching. The second paper, a comparison of reports of randomised controlled trials and systematic reviews in leading UK and US surgical journals, finds little difference across the Atlantic (p. 470). The point here is that the world of surgery has long been criticised for not conducting enough studies with a rigorous design, and an up-to-date evaluation of the published literature should give an indication of any improvement. Disappointingly, the UK and the US turn out to be as bad as each other, with randomised controlled trials and systematic reviews comprising only a small percentage of the publications in these leading journals. Where the UK can certainly learn from the US, argues Donald Irvine, is in the way in which Troy Brennan has lead recertification for internists in the US. The specific lesson is for the Royal Colleges and specialist societies who Liam Donaldson, England's Chief Medical Officer, has handed the responsibility of delivering the recertification element of revalidation for their members (p. 430). This is one of many significant proposals presented by Donaldson in response to the Shipman inquiry. Irvine gives the proposals a vote of confidence with some important caveats, particularly with regards to undergraduate education and the future role of the GMC. Irvine believes, some might think contentiously, that the council of the regulatory body should be ‘disbanded and its successor re-formed with members, medical and lay, who can give it a convincing fresh start.’ Do you agree? The Chief Medical Officer has asked for your views and so does this Journal—from either side of the ocean.

Patterns of diagnosis for colorectal cancer (CRC): Screening detected versus symptomatic presentation

1023 Background: Colorectal cancer (CRC) is a leading cause of cancer death in North America; studies have shown that screening improves survival. Conducted in British Columbia, Canada, this study was conducted to identify the proportion of screening-eligible patients with sporadic CRC who are detected by screening tests versus symptomatic presentation,and to compare baseline patient and tumor characteristics of these two groups. Methods: This retrospective cohort study identified 571 cases via the BC Cancer Registry of patients age 50 years and older presenting with first diagnosis of invasive CRC between Nov. 2002 and Apr. 2003. Patients with non-adenocarcinoma histology, HNPCC or FAP were not included. Self completed questionnaires were mailed to all patients to capture: prior screening history, screening versus symptomatic presentation, and demographic information. All respondents charts were then reviewed to corroborate screening information, and to obtain pathological information including TNM stage, grade and site (proximal versus distal colon versus rectal). Results: Of 212 eligible respondents (37% response), only 14 of 212 (6.6%) patients with a new CRC were detected via screening versus 198 of 212 (93.4%) presenting with symptoms. Respondents were average age at diagnosis 69 years, 59% male, 91% Caucasian, 37%rectal, and 18% M1 at diagnosis. No significant differences in the age, gender, ethnicity, socioeconomic status, tumour stage and site were detected between the screened versus symptomatic groups. Only 33 of 212 patients (15.6%) reported ever having a screening test. 19 of 198 cancers (9.6%) were diagnosed by symptomatic presentation despite a compliant screening history. Conclusion: Despite universal health-care access in British Columbia, only 7% of patients with a new diagnosis of CRC were detected via a screening test. Furthermore, only 15% of screening-eligible respondents have ever been screened. There were no differences in patient demographics or stage of disease at presentation but numbers in the screening cohort were limited. Significant effort is required to increase knowledge and compliance for CRC screening. No significant financial relationships to disclose.

Some Interesting Lessons From Canada

Back to table of contents Next article Taking IssueFull AccessSome Interesting Lessons From CanadaSteven S. Sharfstein, M.D., Steven S. SharfsteinSearch for more papers by this author, M.D., president and chief executive officer, Sheppard Pratt Health System, and president, American Psychiatric AssociationPublished Online:1 Mar 2006https://doi.org/10.1176/appi.ps.57.3.297AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Many psychiatrists, including myself, advocate for universal access to health care for all Americans. I have always favored a single-payer approach like the Canadian system, in which everyone is covered for needed treatment, including psychiatric treatment. A key barrier to gaining access to care is economic discrimination, and the push toward parity in this country is a major effort to overcome the historic difficulty of our patients' and families' receiving effective care. We often point to Canada as the model of nondiscriminatory coverage and equal access for all.But what if a universal, single-payer approach provides for better access for people with higher incomes and lower morbidity than for those in lower socioeconomic groups with serious mental illness? What if parity does not lead to equity? A study by Steele and colleagues in this issue of Psychiatric Services demonstrates that in the Toronto area, beneficiaries in higher socioeconomic neighborhoods were nearly twice as likely as those in lower socioeconomic neighborhoods to use psychiatric care. More visits, more claims, and lower morbidity all characterized the claimants in the higher socioeconomic neighborhoods.This well-designed study demonstrates to those of us who advocate for a Canadian style of universal insurance that equal access to care with no financial barriers is not equal for all people. The disconnect between service need and service use by socioeconomic class reflects issues such as language and cultural barriers, stigma, and the fact that psychiatrists prefer a caseload that consists of mildly depressed or anxious patients who come regularly for visits rather than patients with chronic psychosis or addiction who may miss appointments and have emergency needs. Regardless of the reasons for this disparity in access to care, one question must be, Why should everyone pay taxes if people from higher socioeconomic strata use services disproportionately? Should these less ill, wealthier patients pay for more of these services themselves?The single-payer Canadian system has no copayments or deductibles and no managed care. Should these economic incentives be introduced for persons of a higher socioeconomic status, and if so, how? Will these incentives undermine the basic goal of universal coverage and access? In this country, we use copayments and deductibles to deal with issues of use and potential overuse of services. In addition, we use managed care reviewing the "medical necessity" of treatment. Would managed care effectively address the equity issue in Canada? In a universal health care access plan in the United States, could managed care help avoid the distributive equity problem experienced in Canada? We will not overcome the equity problem of equal access to care by just providing economic access. We need to do more. FiguresReferencesCited byDetailsCited ByBMJ Open, Vol. 5, No. 3BMC Health Services Research, Vol. 15, No. 1Mental Health Service Use Among Chinese Adults With Mental Disabilities: A National SurveyNing Li, Ph.D., Wei Du, Ph.D., Gong Chen, Ph.D., Xinming Song, Ph.D., and Xiaoying Zheng, Ph.D.1 July 2013 | Psychiatric Services, Vol. 64, No. 7Journal of Contemporary Psychotherapy, Vol. 39, No. 2Perceived Barriers to Mental Health Service Utilization in the United States, Ontario, and the NetherlandsJitender Sareen, M.D.Amit Jagdeo, M.D.Brian J. Cox, Ph.D.Ian Clara, M.A.Margreet ten Have, Ph.D.Shay-Lee Belik, B.Sc.Ron de Graaf, Ph.D.Murray B. Stein, M.D., M.P.H.1 March 2007 | Psychiatric Services, Vol. 58, No. 3LettersPhelps M. Robinson, M.D.1 June 2006 | Psychiatric Services, Vol. 57, No. 6LettersRobert Sommer, Ph.D.1 June 2006 | Psychiatric Services, Vol. 57, No. 6LettersH. Steven Moffic, M.D.1 May 2006 | Psychiatric Services, Vol. 57, No. 5LettersJennifer M. Park, M.D.Ravi Hariprasad, M.D.Lawrence T. Park, M.D.1 May 2006 | Psychiatric Services, Vol. 57, No. 5LettersJordana R. Muroff, M.S.W., Ph.D.Scott Y. H. Kim, M.D., Ph.D.1 May 2006 | Psychiatric Services, Vol. 57, No. 5LettersEllen M. Weissman, M.D., M.P.H.Dawn M. Moot, M.A.Susan M. Essock, Ph.D.1 May 2006 | Psychiatric Services, Vol. 57, No. 5 Volume 57Issue 3 March 2006Pages 297-297 Metrics PDF download History Published online 1 March 2006 Published in print 1 March 2006

Health Security for All: Dreams of Universal Health Care in America (review)

Reviewed by: Health Security for All: Dreams of Universal Health Care in America Jill Quadagno Alan Derickson . Health Security for All: Dreams of Universal Health Care in America. Baltimore: Johns Hopkins University Press, 2005. xii + 240 pp. $30.00 (0-8018-8081-5). In the past decade there has appeared a virtual cottage industry of books on the many failed attempts to enact national health insurance across the twentieth century. Yet anyone who wonders whether there is anything new that can be said about this issue must read Alan Derickson's marvelous book, Health Security for All. Unlike his predecessors who have focused on the politics of health policymaking, Derickson traces the evolution of a societal ideal—universal coverage—and the ways in which reformers have sought to translate that ideal into a plan of action. Interestingly, the concept of universal health care has not necessarily meant an entitlement to care, nor has it meant government financing of health-care services. During the Progressive Era, the first proposals for state health insurance promoted by the American Association for Labor Legislation were far from universal. Excluded from the AALL plan were the elderly, the permanently disabled, the self-employed, agricultural laborers, domestic workers, and all irregularly employed [End Page 206] 206 workers (a provision that effectively ruled out most women). Not until the 1920s did universalism become an ideal. In that period, elite reformers based in medical and public health schools led the drive to make medical care accessible to everyone. One of the main proponents of universal care was the American Medical Association, which nonetheless rejected the idea that this care would be provided through the government. All efforts to increase the public provision of care, whether through county health centers, health services for mothers and infants, or even visiting nurses, were vehemently opposed by the AMA. In the 1930s the Committee on the Costs of Medical Care voiced support for the concept of universalism but disagreed on a course of action that would make health care accessible to everyone. Yet it was in this period that the first notion of health care as a social right began to take hold, with organized labor at the forefront of the debate. By the 1940s the concept had coalesced into a proposal that truly would have provided universal health-care access. The goal of universal entitlement faded from view with the collapse of the health-care rights campaign in the postwar period. Instead, voluntary health plans spread rapidly in the 1940s and 1950s, making it appear that private insurance would eventually cover the entire population. As Derickson aptly points out, the success of the voluntarist approach demobilized the core constituency for a universal public insurance program. Universalism was revived in the early 1970s, and then again in the 1990s when President Clinton proposed his own plan for universal access. By then, however, the political will had dissipated. The result of a century-long debate over universalism has been a residual social-policy model in which the government serves as the last resort for the marginal segments of society. I laud Derickson's fresh approach to health-policy history with its focus on the diverse visions of how best to provide health protection and the amazing array of plans designed by reformers to reach this goal. Yet his discussion of the varying interpretations of universality would have been strengthened if he had provided more historical context. How did the ideological, political, and economic forces in each period influence the salience of universality and the way it was interpreted by the public? Is it likely that the United States will ever achieve universal coverage or guarantee universal access to health care? Derickson suggests that universality can be achieved if reformers work to build a mass movement among the uninsured, minority-rights advocates, progressive faith-based organizations, children's advocates, and feminist groups. Such a strategy can succeed only if these various constituencies can agree on specific goals—a task that has proved elusive in the past. Health Security for All provides both a way for reformers to understand these past failed efforts and a blueprint for crafting a message for the future. Jill Quadagno...

Colorectal Cancer Screening: Opportunistic or Organized?

Colorectal Cancer Screening: Opportunistic or Organized?

Controversial Health System Overhaul Returns to National Agenda

Back to table of contents Previous article Next article Health Care EconomicsFull AccessControversial Health System Overhaul Returns to National AgendaKate MulliganKate MulliganSearch for more papers by this authorPublished Online:3 Oct 2003https://doi.org/10.1176/pn.38.19.0021An estimated 41 million Americans lack health insurance, while many of those with coverage face escalating premiums and copayments and decreasing benefits.Those recent signs of crisis within the health care system have led to the revival of an idea that has been implemented by most developed nations, but frequently dismissed in the United States as politically unfeasible.More than 7,000 physicians have signed on to a proposal for a single-payer national health insurance (NHI) program, which would be an “expanded and improved” version of Medicare.The proposal, which is outlined in the August 13 Journal of the American Medical Association, is supported by former U.S. Surgeon Generals David Satcher, M.D., and Julius Richmond, M.D., and by Marcia Angell, M.D., former editor of the New England Journal of Medicine.Angell said, “In the current economic climate, we can no longer afford to waste the vast resources we do on the administrative costs, executive salaries, and profiteering of the private insurance system.”She and other authors of the JAMA article target costs related to private insurance companies and health maintenance organizations (HMOs) as the source of savings that could be used to increase access to health care.Private health insurers and HMOs consume 12 percent of premiums for overhead, according to the article, while both the Medicare program and Canada’s single payer health system have overhead costs below 3.2 percent (see Original article: page 25).The authors said, “Our multiplicity of insurers forces U.S. hospitals to spend more than twice as much as Canadian hospitals on billing and administration; forces U.S. physicians to spend vast amounts on billing; and nourishes a panoply of business consultants, coding software vendors, and other satellite businesses.”The authors observed, “In this market-driven system, insurers and providers compete not so much by increasing quality or lowering costs, but by avoiding unprofitable patients and shifting costs back to patients or to other payers.”According to the single-payer proposal, patients could choose to go to any doctor and hospital. Most hospitals and clinics would remain privately owned and operated, receiving a budget from the NHI program to cover operating costs. Physicians could continue to practice on a fee-for-service basis or receive salaries from group practices, hospitals, or clinics.Investor-owned HMOs and group practices would be converted to not-for-profit status. Only institutions that actually deliver care could receive NHI payments.APA has not taken a position on single-payer legislation. An action paper approved by APA’s Assembly at its May meeting, however, requested that the Association adopt a policy encouraging the federal government to oversee the establishment and funding of universal health care access, which would “improve efficiency while maintaining quality.” The Joint Reference Committee referred the item to the Council on Advocacy and Public Policy and the Committee on Government Relations with a request that their comments be submitted to the Board of Trustees at its meeting later this monthAs reported on the Web site www.kaisernetwork.org (August 13,15, 20), editorial reaction acknowledged the seriousness of the problems in the health care system, but was not unified about the feasibility of the single-payer approach.A Seattle Post-Intelligencer editorial argued, “It’s an excellent measure of the depth of the American health care crisis that a group of doctors has proposed a national health plan.” The Arizona Daily Star editorial claimed, “[Given the] abysmal status of the health delivery system in the United States, [the proposal] is a shot in the arm for a national health care system.”Investor’s Business Daily said proponents of the proposal would “rather provide third-rate health care for all by making us all pay higher taxes than let Americans take care of their own problems as individuals making choices.” The Raleigh News & Observor called the proposal a “good start. [Its] basic principles are sound.”Donald Palmisano, M.D., president of the AMA, said in a written statement of opposition, “Long waits for health care services, a slowness to adopt new technologies and maintain facilities, and development of a large bureaucracy that can cause a decline in the authority of patients and their physicians over clinical decision making are all hallmarks of a single-payer system.”The American Association of Health Plans, in a written statement, maintained that the proposal would be “dead on arrival” in Congress.Information about the proposal and reaction to it is posted at the Physicians for a National Health Program Web site at www.pnhp.org. ▪ ISSUES NewArchived

MSJAMA. State ballot initiatives for health care reform.

THROUGHOUT THE LAST DECADE, PHYSICIANS IN SEVERAL STATES have used ballot initiatives as a way to become politically active in campaigns intended to return to them some degree of control over their practices and the patientphysician relationship. Ballot initiative campaigns also provide medical students unique opportunities to work with physicians to affect health policy and hone their political advocacy skills. The initiative process, available in 24 states, allows citizens to circumvent the slower legislative process to adopt laws and amend state constitutions. In recent years, the initiative process has been used to advance controversial policies that at times have been blocked or ignored by legislature. In most states, an initiative must be affirmed by a simple majority of voters to carry the force of law. Of the more than 70 citizen-driven initiatives on election ballots in 2000, 11 addressed health care issues, including allocation of tobacco settlement funds, legalizing physicianassisted suicide and medical marijuana, and universal health coverage. One such campaign was the Massachusetts Health Care Reform Ballot Initiative of 2000. This ballot initiative grew out of the discontent of Massachusetts physicians with the use of financial incentives to limit patient care and control costs, the pressure to increase patient volumes as a means to increase profits, and policies that restrict a patient’s freedom to choose or change his or her physicians. A group of 2300 physicians and health professionals drafted a ballot initiative calling for universal health care access, managed care reform, and a moratorium on the conversion of nonprofit hospitals and health plans to for-profit status. In addition to participating in political strategizing and canvassing, medical student interns worked alongside physicians and other volunteers to collect more than 100000 signatures from voters in Massachusetts to secure placement of the initiative on the November 2000 ballot. The measure, despite minimal fundraising and organization, narrowly failed at the polls, with 48% of the vote. In a poll taken about a month before voting, 72% of respondents reported that they supported the initiative. The opponents, including health maintenance organizations, several Massachusetts lawmakers, business associations, and other insurers, spent $5 million on an advertising campaign that portrayed the reforms as flawed, bureaucratic, and costly. The proponents, on the other hand, invested only $100000 in their campaign. Although the initiative did not become law, it helped renew legislative interest in health care reform. Its popularity, combined with other polling data, indicated that health care reform was important to the citizens of Massachusetts and thus prompted the Massachusetts legislature to enact a managed care reform bill that had been stymied in the legislature for more than 3 years. The bill passed by the legislature affirmed the autonomy of physicians to make clinical treatment determinations for their patients which had been restricted by managed care organizations. In addition, it strengthened protection from gag clauses that prevented physicians from discussing with patients the provisions of their health plan. The managed care bill addressed many of the issues cited as contributing to physicians’ perceived erosion of autonomy and dissatisfaction. Although the Massachusetts Health Care Reform Initiative failed at the polls, it was indirectly successful. A wellcrafted and organized initiative campaign may serve as the impetus for lawmakers to more expediently enact important health care legislation. Medical students have also participated in similar ballot initiative campaigns in California in 1994 and Washington in 2000. In the face of corporate interests that usually dominate the initiative process, physicians and medical students have the unique advantage of direct health care experiences. These can be integrated with the political expertise of professional campaign staff to build coalitions, fundraise, advertise, and reach out to voters. Initiatives can be an efficient method for physicians and medical students to influence health care legislation, advance health care reform initiatives, and draw attention to policy issues that affect medical practice and patient-physician relationships.

O-115 Variances in lung cancer outcomes in a universal access health care system: Is there a need for a navigator program for lung cancer patients?

O-115 Variances in lung cancer outcomes in a universal access health care system: Is there a need for a navigator program for lung cancer patients?

On Its Golden Anniversary, Assembly Tackles Diverse Agenda

On Its Golden Anniversary, Assembly Tackles Diverse Agenda

Why justice is good for our health: the social determinants of health inequalities.

We have known for over 150 years that an individual’s chances of life and death are patterned according to social class: the more affluent and educated people are, the longer and healthier their lives. These patterns persist even when there is universal access to health care – a fact quite surprising to those who think financial access to medical services is the primary determinant of health status. In fact, recent cross-national evidence suggests that the greater the degree of socioeconomic inequality that exists within a society, the steeper the gradient of health inequality. As a result, middle-income groups in a less equal society will have worse health than comparable or even poorer groups in a society with greater equality.

Balance and Limits: Modeling Graduate Medical Education Reform Based on Recommendations of the Council on Graduate Medical Education

National commissions, medical philanthropies, scholars, and policy analysts agree that the key to improved health care access and cost containment is a physician workforce built on a generalist foundation. They propose a national system to allocate a specific and limited number of graduate medical education (GME) positions. The Council on Graduate Medical Education recommended that training positions be limited to 110 percent of the graduates of U.S. allopathic and osteopathic medical schools and that the system graduate 50 percent into primary care practice (50/50-110 proposal). The 50/50-110 option would significantly modify GME training: surgical and support specialty positions would be reduced, and increased numbers of medical and pediatric residents would enter general practice. This workforce composition would facilitate provision of universal health care access and help control costs--the basic tenets of reform.

Families U.S.A. (United for Senior Action) Foundation.

Families U.S.A. (United for Senior Action) Foundation.