New York's Local 6 has achieved many of the goals of single payer reform by working from the bottom up. They are providing very comprehensive health care services at only about one-third of the costs of other New York plans, and with the highest patient satisfaction ratings.

The key is that they have been able to to create a health care delivery infrastructure dedicated to optimal patient care that is removed from our current dysfunctional system dominated by insurer middlemen. This was all about patients, not insurers.

One important example of the difference is that they recognized that co-pays and deductibles were barriers to care. As Dr. Greenspan says, "They do the opposite of what is claimed." People should have unlimited access to primary care. To show how wrong the policy community is in their support of cost sharing, Dr. Greenspan's group has eliminated these barriers, yet their costs are far less than New York's least expensive HMO. You do not need deductibles and co-pays to control health care spending.

Although this was a bottom up success, it is improbable that it could be used as an insurance model for the rest of the nation. Their success was dependent on the unique efforts of a local union. Also their members have no coverage outside of their system. Our health care delivery systems and our health care financing systems are too fragmented to permit the creation of a nation of Local 6-type institutions, especially when the solidarity characteristic of unions is lacking in most other environments.

Although a top down approach contrasts sharply with what Local 6 has done, nevertheless, a well-designed single-payer model can accomplish the same results, with the added benefit of ensuring patient choice of their health care professionals and institutions. But we'll have to get the private insurers out of the way. They would never accept a system with so little money in it. - Don McCanne, MD, Physicians for a National Health Program