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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

A Path to Health Care for All?

Health care coverage for every single person in the United States is coming. You may not be able to see it from the brutal politics of the moment. But if we step back from the health care battles in Congress and look instead at the social and economic forces brewing, as well as the new frontier of medical science, there is a path that eventually will prevail in ensuring that everyone has access to the affordable care they need.

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Short-term: Health Care Deadlock

The politics of health care has become a cynical and brutal blood sport. There have been successes over the last several decades in covering more people and improving access to affordable coverage. But families across the country are now acutely aware that this issue, which so intimately affects them, is being used to score political points, finance campaigns, and fund other priorities. The dissatisfaction and concern this brings is important to pay attention to.

The public is used to a certain amount of partisanship, but over the last decade it has exceeded the normal bounds both in rhetoric and in the willingness to ignore public will for partisan gain. Since the Affordable Care Act (ACA) passed in 2010, Republicans have voted more than 50 times to repeal the law and made those symbolic acts a centerpiece of campaigns that led them to gain about 70 seats in Congress over 3 cycles. And while it’s hard to tie down national fundraising figures, one prominent national Republican told me that he believes health care “repeal and replace” post-ACA was far and away the most significant fundraising vehicle, accounting for hundreds of millions of dollars of political contributions. Running against the weaknesses in the law proved to be far more politically profitable than working to fix them.

Democrats aren’t immune from using health care to their political advantage. Should Republicans repeal even a part of the ACA, there is good reason to believe that Democrats will turn this into a huge electoral advantage in 2018.  The potency of health care as a messaging vehicle is only getting more intense on both sides. Health care as a hyper-political issue reigns supreme.

Looking only at the near term, there is no reason to believe our deadlock will subside.

Long-term: Health Care for All

To overcome the health care political deadlock, something will have to break the fever. And there is good reason to think this will happen. For one, there is growing support for the idea among the public that access to affordable health care should be guaranteed to all. Although Washington can often remain out of step with the public for an extended period of time (see gun safety regulations and prescription drug cost controls, for example), there are social, economic, and demographic forces that will be hard to ignore for long.

A little history helps. In the 20th century, the rise of employer-based and government-funded health care coverage came along with the rise of the middle class, massive factory employment and unionization, and the aging of the population. Today, automation and globalism are changing traditional employment and the way millions access insurance. Our system must adjust again as the “gig” economy creates new demand for health coverage to be untethered from employment.

Through the years, coverage gaps have closed incrementally and over time—for elderly individuals, children, veterans, and low-income and near-poor families and individuals. The most significant remaining gap today exists mainly in the middle class and those in the new economy: the self-employed, small businesses owners, and independent contractors. This is also a politically important demographic and is the only group not to receive any form of government support for health care. Don’t expect that to last.

Coverage expansion is also likely to be spurred by some galvanizing events. When the public health costs or treatment potential warrant it, we are often compelled to respond. In 1972, we established nearly universal Medicare coverage for people with end-stage renal disease following the rapid development throughout the 1960s of groundbreaking—and expensive—treatment options. Today, mental health and opioid addiction are massive unmet public health needs that require broader national solutions. And recent scientific advances, like gene therapies that are bringing us closer to expensive new cures for things like childhood leukemia will create demand for new pathways to coverage that ensure these treatments are broadly available.

The politics of health care won’t change overnight. Partisanship won’t be going away any time soon. But we have seen the politics change on what were once intractable social issues. Evolving attitudes on the environment, on smoking, on our definition of marriage, have forced our politicians to change. If the public wants guaranteed access to care, they have the power to make it happen.

About the author: Andy Slavitt, MBA, served as the Acting Administrator for the Centers for Medicare & Medicaid Services under President Obama from 2015 to 2017, where he focused on advances in health care coverage and accelerating health care delivery system transformation. He has 2 decades of private–sector health care leadership, both as a senior executive at Optum, a health services and innovation company, and as an entrepreneur. He tweets at @aslavitt. (Image: US Department of Health and Human Services)
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