Health policy trade-offs: keep good, dump bad

By Linda J. Blumberg
Urban Institute, June 2020

Exploring the Five Core Questions Necessary to Evaluate the Trade-Offs Inherent in a Health Reform Proposal

Evaluating the trade-offs inherent in the answers to each of the five core questions below is critical to understanding the philosophical underpinnings and general implications of health reform proposals.

1. How broadly should the costs of the sick be shared with the healthy?
2. How important is reaching true universal coverage? How many US residents must be insured?
3. How generous should federally financed subsidies of premiums and cost sharing be?
4. How should reform options be financed?
5. Should there be regulations limiting the prices paid to health care providers of different types (i.e., hospitals, physicians, prescription drug manufacturers, medical device manufacturers), and if so, how broadly should those regulations apply, and how should prices be set?

Answers to These Five Central Questions Frame Policy Proposals

To illustrate how this five-decision framework clarifies the reforms most frequently discussed, I use three policy examples:

• Full repeal of the ACA
• Build upon the ACA with additional financial assistance and a public option
• Replace the current system with an enhanced single-payer program

(Pages 10-14 provide the author’s answers to each of the five questions for each of the three models listed. Use the link to access the report.)

From the Conclusion

Advocates of various health care reform proposals are quick to extoll the virtues of their preferred reforms. But advocates should acknowledge the trade-offs inherent in their respective approaches. An educated consumer of public policy ideas should be aware that there is no perfect solution. All reforms will yield advantages and disadvantages, gains and losses. The challenge is finding a policy that represents a broadly accepted set of trade-offs. Any one person’s preferred trade-offs will hinge on their individual values and preferences. This brief is designed to help people understand the inherent consequences of different options so readers can make more informed choices about the types of reforms they support.

https://www.urban.org…

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Comment:

By Don McCanne, M.D.

Linda Blumberg is right when she says that we should understand the trade-offs with various health reform policies. But the policies are not neutral from a health care justice perspective. There are beneficial policies and detrimental policies, and we should not grant detrimental policies an equal status just because some individuals place self-interests above the rest of us. Let’s look briefly at the three models of reform she discusses.

Full Repeal of the ACA

1. Sharing health care costs of the sick with the healthy
   • It would increase health care costs for the sick
2. True universal coverage
   • Millions more would be uninsured
3. Generosity of federal subsidies of premiums and cost sharing
   • Insurance costs would increase for individuals and families
4. Financing this reform option
   • Federal support would be reduced
5. Price regulation
   • Reduction of government price oversight

Build upon the ACA with Additional Financial Assistance and a Public Option

1. Sharing health care costs of the sick with the healthy
   • Many of the sick would still face significant costs
2. True universal coverage
   • Many immigrants would still remain uninsured, and others underinsured
3. Generosity of federal subsidies of premiums and cost sharing
   • Subsidies would be expanded but many will still face significant costs
4. Financing this reform option
   • More federal support but inequitable private spending would persist
5. Price regulation
   • Public option would be regulated, but not employer-based plans

Replace the Current System with an Enhanced Single-Payer Program

1. Sharing health care costs of the sick with the healthy
   • All costs care shared equitably through a universal risk pool
2. True universal coverage:
   • All residents are covered regardless of immigration status
3. Generosity of federal subsidies of premiums and cost sharing
   • Financial barriers to health care would be removed
4. Financing this reform option
   • Fully funded through equitable progressive taxes
5. Price regulation
   • Fair prices would be paid through rate negotiation and global budgeting

So let’s accept good policies while rejecting the bad. It’s long past time that we replace the I/me/mine selfish, uncaring policies with we/us/ours egalitarianism so that all of us can have accessible, affordable health care whenever we need it.

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