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September 14, 1994

A Better-Quality AlternativeSingle-Payer National Health System Reform

Author Affiliations

From the Division of General Medicine/Primary Care, Cook County Hospital, Chicago, Ill (Dr Schiff); the Division of General Internal Medicine and the Institute for Health Policy Studies, San Francisco General Hospital, University of California—San Francisco (Dr Bindman); and the Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (Dr Brennan). Dr Bindman is a Robert Wood Johnson General Physician Faculty Scholar.

JAMA. 1994;272(10):803-808. doi:10.1001/jama.1994.03520100065035

MANY MISCONSTRUE US health system reform options by presuming that "trade-offs" are needed to counterbalance the competing goals of increasing access, containing costs, and preserving quality.1,2 Standing as an apparent paradox to this zero-sum equation are countries such as Canada that ensure access to all at a cost 40% per capita less, with satisfaction and outcomes as good as or better than those in the United States.3,4 While the efficiencies of a single-payer universal program are widely acknowledged to facilitate simultaneous cost control and universal access, lingering concerns about quality have blunted support for this approach.

See also p 797.

Quality is of paramount importance to Americans. Opponents of reform appeal to fears of diminished quality, warning of waiting lists, rationing, and "government control."5 Missing from more narrow discussions of the accuracy of such charges is a broader exploration of the quality implications of a universal health

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