AMERICAN JOURNAL OF
Public Editorials Healtli April 1976 Volume 66, Number 4
How Long Must We Wait? EDITOR
Alfred Yankauer, MD, MPH
EDITORIAL BOARD Michel A. Ibrahim, MD, PhD (1977) Chairman Faye G. Abdellah, PhD (1977) Rashi Fein, PhD (1978) Ruth B. Galanter, MCP(1977) H. Jack Geiger, MD, MSciHyg (1978) George E. Hardy, Jr., MD, MPH (1978) C. C. Johnson, Jr., MSCE (1977) M. Allen Pond, MPH (1976) Pauline 0. Roberts, MD, MPH (1976) Ruth Roemer, JD (1978) Sam Shapiro (1976) Robert Sigmond (1976) Jeanette J. Simmons, MPH, DSc (1978) David H. Wegman, MD, MSOH (1976) Robert J. Weiss, MD (1977) STAFF William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director ofPublications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor
CONTRIBUTING EDITORS George Rosen, MD, PhD Public Health: Then and Now William J. Curran, JD, SMHyg Public Health and the Law
There is no shortage of proposals for national health insurance in the United States. Several decades of effort of varying intensity have produced legislation to provide coverage for dozens of beneficiary groups with widely varying eligibility standards, range of coverage, mode of finance and administrative mechanisms. The sum of these parts doesn't even approach a basis for making a whole, and millions of the population remain uncovered or inadequately covered by voluntary and public programs.
Donabedian, in a characteristically sound approach, in this issue of the Journal,' endeavours to analyze some of the basic issues involved in any national health insurance scheme. Although he describes his approach to analysis as simplistic, it has a cutting edge. He sharpens the argument at the very beginning by portraying the dichotomous views of adherents of various proposals. These views are often expressed with almost religious fervor and with limited regard for direct and indirect consequences. By placing them squarely before us, and presenting a framework for analysis of both actions and consequences, Donabedian provides us the opportunity to reexamine our own positions and to know the meaning of where we stand. Meanwhile, as a nation, we are paying the price of our peculiar brand of incrementalism, and the benefits are less than patently obvious. This editorial is written by an American from North of the Border, in Canada where important decisions about health insurance have already been taken. There are many defects in Canada's system and many aspects which only fit Canada's traditions and culture. But Canada's population is universally covered, and does have a broad range of coverage through a system which is administered by accountable public
While I would be the last to suggest that a perfect system has been achieved, it is there, and it can be adapted over time to changing needs and changing times. Various provinces are experimenting with added benefits, different manpower mixes, and different patterns of administration. In the future, some consideration may be given to different modes of remuneration, although this is manifestly a contentious item. Several different ways of financing operating and capital costs of hospitals are being explored. There is both consistency of basic benefits across the country and diversity among provinces in going beyond these basic benefits and in the management of the system. At the same time, there is no one who would turn the clock back to the days before the fundamental decisions were made. By any standard, Canada's health insurance scheme is a success in the eyes of the public. How long must we wait in my country?
SIDNEY S. LEE, MD, DRPH REFERENCE 1. Donabedian, A. Issues in national health insurance, Am. J. Public Health 66:345-350, 1976. Dr. Lee is Associate Dean, Faculty of Medicine, McGill University Montreal, Quebec, Canada
AJPH, April, 1976, Vol. 66, No. 4