The Health Care Conundrum



On Friday U.S. District Court Judge Reed O’Connor found the Affordable Care Act (ACA) unconstitutional. This judicial action throws future insurance coverage for millions of Americans into question and assures health care as a central topic of public and political discussions for the foreseeable future. While this decision does not change ongoing health care operations under current law (due to expected legal challenges), it heightens the uncertainty about the future financing and organization of health care in this country.

What does this mean for the nation and for Missouri? As we consider possible next steps in major health care reform, it is useful to go back a decade and reflect on how the ACA was developed. The ACA was crafted primarily by a multitude of knowledgeable interests with significant stakes in the financing and organization of health care, and the results reflected this process. Unfortunately, the voices of patients and families, especially those most in need of health care, were not front and center in the design and implementation of the ACA. One notable outcome is that the core health care issue facing most of us – affordability – has gotten worse, despite the progress made on many access and coverage issues. Frustrations with widespread challenges in accessing and paying for health care contribute to a sustained ambivalence toward the ACA, despite a recent modest upsurge in support. The experiences of people and communities who want a more affordable health care system need to be at the center of future discussions.

What might a fairer, more affordable health care system look like? About a month or so ago, I wrote about the intersection of fairness and health and how, in health, the reality of inequity is pervasive. The same is true of health care. Coverage for pre-existing conditions, equitable care for rural residents, and truly affordable care for everyone are essential goals for any system.  Multiple examples exist on what a better system could be, and more are likely to be developed. Ideas for fundamental change that seemed infeasible just a few years ago are now being actively presented in leading medical journals. For example, highly respected health economist Victor Fuchs recently argued that the first step in major health reform should be replacing employment-based health insurance. Many other health care reform ideas suggest equally fundamental changes. At the national level, ideas range from a handful of new public plans to be added to the insurance marketplace to a variety of ways to think about expanding Medicare, including lowering the Medicare eligibility age to implementing “Medicare for All.”

At the state level, ideas range from establishing the option to buy into Medicaid via the state insurance exchanges to greater use of waivers to exploit the value of states being the “laboratories of democracy.” Regardless of which health care reform ideas gain traction, the broad social, economic, and political implications will mandate a thorough analysis. A recent study, The Economics of Medicare For All,  examines the economic implications of one proposed model. It shows how a system in which everyone would participate in Medicare could be financed and takes on the important topic of how we could transition from our current employer-based insurance system. As such, it sets the bar for a rigorous and clear analysis of any other proposed major health care reform ideas. Analyses of every serious proposal, whether national or state, should address the thorny implementation issues and potential adverse consequences in moving from our current system to any new financing and organizational arrangements.

Our health care system is one sixth of our economy and is bizarrely complex to the average American, which in many ways also makes any substantial change to our national or state health care systems difficult. So how can we learn from the adoption of the ACA and consider what needs to happen to inject widespread public will into health care’s future?

I’d suggest three things to consider:

  1. Civic participation. This issue affects us all, and we need broad-based engagement in a variety of venues to assure that public voices are heard and respected. 
  2. Trusted interpreters and education. We can’t all be experts, and the details matter.  So, we need a strong, effective, and trusted news infrastructure to inform and explain health care proposals like a Medicaid buy-in or “Medicare for All.” There will be many proposals, and widespread understanding of these will help us reach a better outcome. 
  3. Compromise.  Ultimately any major step forward must take into consideration many competing private interests as well as the public good. Our government institutions are set up to do that work, and that is who we should trust and hold accountable; that is where the ultimate responsibility lies. 

These basic ingredients provide a start toward (solving our conundrum) widespread public support. Sure, the realistic timeline for actual progress at the national level is several years at the earliest, but action on major health care reform at the state level could come sooner. These three components will help Missouri communities contribute effectively to the multifaceted process of deciding via our democratic institutions what we as a state want for the health of our residents.