It’s a perfect time to reflect on the national health policy debate over coverage. Not the one we’re having now, but the one we are destined to have sometime in the 2020s. Going back at least as far as Medicare and Medicaid in the 1960s, once a decade or so, we contemplate major national coverage reforms to the US health care system. While enthusiasm builds in some circles that the next debate has the potential to bring us full universal coverage, the lessons of our recent efforts tell us we often come away with far less than we should.
Andy Slavitt, MBA
Recent health policy debates have brought us a number of advances, such as prescription drug coverage for seniors in 2003, as well as the first significant reduction in the number of uninsured people in decades in 2010 that resulted from passage of the Affordable Care Act (ACA). But these advances have come at a cost. Increasingly partisan votes have left many feeling embittered and without the bipartisan commitment to improve the law once a bill passes. In the most recent and ongoing debate over the House and Senate ACA repeal bills, we failed even to have public hearings to call on the nation’s expertise. Health care legislation has ceased to be about solving problems for ordinary families and has instead become a scorched-earth partisan battle. For our next policy battle, we need to do better.
With the luxury of a decade to plan for sweeping legislation, what would we do differently? This isn’t an academic exercise. Too often, by the time we get into a policy negotiation, our best options are long off the table—as we have had limited public and stakeholder engagement and not laid sufficient groundwork for system transformation.
Here are 4 recommendations for things we should do today in the public and private sectors to give our next run at health care coverage the greatest chance of success.
Universal coverage is growing in popularity in public polls, but getting support for the details of real reform is more challenging. With the majority of people in the United States covered through employer-sponsored plans, gaining support for a new plan will mean convincing those people that they won’t lose out or be worse off in a major reform. Before we develop new policies, we should listen carefully to the public and understand the kitchen-table issues they care about and how they consider important trade-offs.
If we aim for reforms to be lasting, our goal should be to develop policies that 60% to 70% of the public supports. If we do that, the bipartisan political support necessary to keep our system stable should follow.
Our goal should be to develop policies that we have real-world experience with, so we can avoid think-tank fantasies that either overstate the power of free markets or fail to see the unintended consequences of government intervention. Romneycare in Massachusetts allowed policy makers and the Congressional Budget Office to evaluate the state’s experience with insurance exchanges when drafting the ACA.
We can learn much from what happens in the states. Does Medicaid buy-in work? How about a public option sitting alongside private market ones? Is there a role for an all-payer system? Are health saving accounts a good taxpayer investment?
The biggest obstacle to transformative health care policies is the high cost of care. Very few US consumers can afford the cost of their own care without significant support from the government in the form of tax credits, subsidies, or direct government programs. Before we increase access to coverage, we should focus on real-world reforms that will reduce the cost of prescription drugs, care for people in lower-cost settings, and reduce ballooning administrative costs. Any new coverage legislation will also need to include another series of scoreable “pay fors,” spending cuts or tax increases to balance the new spending. Those pay fors should aim at the excesses in the system but also create incentives to deliver more with less.
New policies will deliver the results we want only if the health system can successfully implement them. As we have learned since implementing the ACA, expanding access means expanding our ability to treat the most vulnerable populations who don’t have a regular source of care. Hospitals and integrated delivery networks will need to learn how to care for people with low incomes, including Medicaid beneficiaries and people who qualify for both Medicaid and Medicare (dual eligibles). Systems should be experimenting now with addressing social determinants of health; home- and community-based models, including home monitoring and telemedicine; and innovations in costly areas of care, such as dialysis for chronic kidney disease, mental health, and finding better models for end-of-life of life care.
This current debate isn’t over as long as the administration clings to talk of repealing the ACA. Still, the movement toward a single-payer system or another variant is beginning. There will be much written about the ideas that will shape our future. Whatever those ideas are, if we want them to succeed, we must begin now to create the ingredients for successful legislation finally worthy of our country.
Corresponding Author: Andy Slavitt, MBA (email@example.com).
Published Online: August 30, 2017, at http://newsatjama.jama.com/category/the-jama-forum/.
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Slavitt A. Our Next Health Care Debate. JAMA. 2017;318(13):1212–1213. doi:10.1001/jama.2017.14471
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