In a previous post, a diagnosis of American health care ills revealed that – for various reasons – the American Health Care Act is the wrong medicine. In this post we build on that diagnosis to explore prescriptions for giving the country the right medicine, suggesting a pathway to healing the system and improving the nation’s health.
The country’s health care ills are not an acute flare up; they are a chronic (deeply embedded) affliction that developed over many decades. Too many people are without sufficient insurance coverage and find health care too costly, and, frankly a nightmare to navigate. In addition, the health outcomes it produces are worse than those achieved in other economically developed countries. So we have a system that doesn’t deliver on what people want or need.
People care most about having health insurance, reasonable access to care without hassle, and the ability to pay for their care – including premiums, deductibles, co-pays, and drug costs – all within an equitable framework. In brief, affordable coverage to accessible care. What do conversations across the country tell us about the right treatment for our system’s ills?
Discussions among grassroots groups and analyses by health policy experts reflect a growing national consensus for movement toward both more affordable care and universal health insurance coverage. Reforming the financing and organization of the nation’s health care delivery system must go hand in hand with policy to adopt universal coverage. The social, economic, and moral arguments for reform reinforce that delivery system reform and policy reform are inextricably connected.
On coverage, the Affordable Care Act (ACA) moved the country forward, but significant gaps remain amidst the patchwork of coverage via employment-based insurance, Medicare, Medicaid, and individual insurance markets. Policy analysts across the political spectrum have offered solutions for closing the remaining gaps. The most far-reaching would entail taking one component, i.e., Medicare, and expanding it to the entire population. Three other proposals would close gaps by:
- Lowering the age of Medicare eligibility
- Allowing everyone under 65 to enroll in Medicaid
- Expanding the individual insurance markets, while reinforcing individual responsibility by strengthening insurance mandates and increasing the penalties for being uninsured
Regardless of which pathway the country takes to get to universal coverage, all of us will need to swallow some medicine, and take some responsibility in paying our share and using the system prudently. No system will work well without universal coverage and the resources that we collectively contribute to finance it. Those resources must be measured carefully and the pathway must include adopting robust mechanisms to bring health care costs under control. This will be the most contentious part of the work, because many, if not most, of the institutional interests benefitting from the current system will resist these changes. The carrots that enticed these interests to support the tepid steps toward affordability in the ACA are less available now. Nevertheless, if we are to get to universal coverage, it must be accompanied by affordable and accessible care because the country needs to come to grips with our disproportionately high spending on health care. This means the system needs to be designed, managed, and regulated with consumers in mind.
Developing a national consensus on embracing a pathway to universal coverage and affordable care will take time and be hard work. It will require widespread discussion about values and tradeoffs. It will require patience, wisdom, and leadership; and it will require learning. We are already seeing lessons offered from the experience of other countries – the risks of block grants in Canadian provinces and the benefits of community health centers in Spain. States can also be laboratories for learning, such as watching California’s current consideration of a single-payer initiative.
In the meantime, policymakers should “do no harm” to the country’s health and stabilize current coverage while supporting and strengthening ongoing delivery system reforms. Some of the current pillars of coverage may not be kept in the long run, but none should be discarded until an agreed upon replacement is ready to implement in conjunction with progress on financing and organizational efficiencies.
It is worth repeating that much of the controversy about our health care system’s ills are not about the ACA per se. The problems that need to be fixed were pre-existing conditions when the ACA passed. The ACA helped, but the chronic illness remained. And it is peoples’ experiences with the chronic problems of the system that have shaped their views of the ACA. Indeed, views of the ACA – favorable or unfavorable – depend on peoples’ own premiums and out-of-pocket costs, even if their coverage is not via the ACA. So we need to move beyond the unbridled and unproductive focus on the ACA to considering how we move forward to what the country needs and wants – universal affordable coverage to accessible health care.