By Matthew Fiedler, Ph.D.
The New England Journal of Medicine, September 24, 2020
There is broad agreement that policy changes could improve the U.S. health care system. But that is often where agreement ends, and different policymakers have starkly different visions for how policy should change. While Covid-19 is dominating policy discussions for now, two other health care policy issues are still poised to feature prominently in the 2020 U.S. elections: what role government should play in ensuring broad health insurance coverage and how to cope with the lack of competition in many health care provider markets.
To understand current U.S. debates over health insurance, the first step is to recognize that there is no consensus about what problem policymakers should aim to solve — a gap that reflects both different assessments of the facts and, probably more important, differences in values. At the risk of oversimplifying, there are two broad camps. The first holds that federal policy should aim for universal coverage and deeply subsidize coverage for low- and moderate-income people, a position that reflects judgments that health insurance substantially improves health and financial security, that improving the financial well-being of lower-income people is particularly important, and that governments should have broad latitude to intervene in the health care system to improve their citizens’ well-being. Policymakers in the second camp generally disagree with each of these judgments, at least to some degree, and believe that even existing federal coverage programs, particularly those serving lower-income people, are too expansive.
Policymakers in the first camp have generally supported one of two broad policy approaches. The first seeks to fill the gaps in the United States’ current patchwork coverage system while preserving its overall structure, effectively continuing the approach taken under the Affordable Care Act (ACA), which drove a large decline in the uninsured rate over the past decade. These approaches would make coverage more affordable for people who currently lack it, including by encouraging all states to expand their Medicaid programs under the ACA to cover all low-income adults (or creating alternative mechanisms to cover this group) and by expanding the ACA’s subsidies for people who purchase coverage on the individual market. They would also seek to ensure that people actually enroll in coverage for which they are eligible, through streamlined enrollment procedures and, in some cases, automatic enrollment. Democratic presidential nominee Joe Biden has adopted this basic approach to expanding coverage, although the form of autoenrollment in his plan would fall short of achieving universal coverage.
Others in the first camp have supported instead replacing the current U.S. coverage patchwork with a single integrated coverage program financed entirely by tax dollars. Many proposals in this vein, including the one from Senator Bernie Sanders (I-VT), would enroll everyone in a government-run plan with minimal cost sharing, but such a program could in principle include cost sharing or allow a choice of private plans. Relative to approaches to expanding coverage that maintain the current U.S. patchwork of coverage types, this type of system would most likely be simpler and thus impose smaller administrative and hassle costs on patients and health care providers, but it would require the federal government to collect much more revenue and would involve much greater disruption to existing coverage arrangements. Proposals eliminating a role for private insurers would be particularly simple but would forfeit any benefits that may flow from innovation by private insurers in areas such as benefit design or utilization management.
By contrast, the Trump administration’s policy agenda places it squarely in the second camp. As the president entered office, his administration supported legislation that would repeal or sharply curtail many of the ACA’s coverage provisions, including its Medicaid expansion, subsidies for obtaining coverage on the individual market, and the mandate that all individuals obtain insurance, while also reducing eligibility and funding for the pre-ACA Medicaid program. The Congressional Budget Office concluded that several proposals the administration supported would have increased the number of uninsured by more than 20 million, thereby returning the uninsured rate to roughly its pre-ACA level, and would have substantially reduced federal spending. Although only the individual mandate was ultimately repealed, the Trump administration has included similar proposals in its annual budgets and is asking the U.S. Supreme Court to strike down the entire ACA in a case being heard this fall.
(The article also discusses market concentration, competition, impact of COVID-19, and other policies such as capping prices or introducing a public option.)
Regardless, in light of the deep differences among 2020 candidates, voters’ choices this fall — whether driven by health care or other issues — will shape the health care system for years to come.
By Don McCanne, M.D.
Matthew Fiedler has provided us with an extremely brief but fairly concise description of the major alternatives in health care reform: one camp holds that federal policy should aim for universal coverage with government subsidization to make health care affordable; the other camp believes that even current, inadequate federal coverage programs are too expensive and should be curtailed.
The first camp is divided between those who would replace the current U.S. coverage patchwork with a single integrated coverage program financed entirely by tax dollars (single payer Medicare for All), and those who would fill the gaps in the United States’ current patchwork coverage system while preserving its overall structure (expand the Affordable Care Act).
The second camp is exemplified by the Trump administration’s efforts to reduce or eliminate existing government health programs even though that would greatly increase the number of uninsured while substantially reducing government spending on health care.
Fiedler states, “there is no consensus about what problem policymakers should aim to solve — a gap that reflects both different assessments of the facts and, probably more important, differences in values,” but that the forthcoming election “will shape the health care system for years to come.”
This choice matters. Will we have essential health care for everyone that is affordable for each of us, or will we perpetuate financial hardship, personal suffering and even premature death by minimizing a government role in health care?
Will those who support financial hardship, suffering and death please stand up so we know who you are. I don’t see anyone standing. So let’s get with it in ending this scourge on America.
Vote. And then follow up with the demand to our elected public stewards that they do the right thing.
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