Affordable high-quality health care for all Americans is the easiest problem to fix in the US, Ch 1 excerpt: HOW THE U.S. WON HEALTH SECURITY FOR ALL – A NOTE FROM 2035, by Alan Sager, PhD, Health Reform Program, Boston University School of Public Health
The Easiest (2025) online access here
A number of large accidents and mostly well-intentioned but unpredictably unfortunate choices had combined to shape U.S. health care in 2025. That care was widely believed to be ineffective, unaffordable, unsustainable, and unequal. It was anarchic, unaccountable to anyone for anything, and prone to gross inefficiency and substantial theft.
But it was also well-entrenched and very hard to change. It had support from many of those patients able to afford and obtain good care, from many doctors and other caregivers, from insurance companies, and from those suspicious of reforms who could not see a path forward to anything better.
Its critics were mainly those who could not afford care or sought reform in coverage, cost, caregiver availability, and equity that other rich democracies had achieved in recent decades.
In 2025, roads to health care reform seemed blocked. Political progress was difficult. Congress was not willing to vote for changes that lacked strong backing. No useful reforms had that strong backing. Few state governments were competent to put their arms around health care problems or devise and implement remedies. The very notion of relying on politics to substitute for markets to fix health care was rejected by many Americans and their representatives. Support for covering all people, removing financial barriers to care, and containing health care costs was broad but generally shallow and disorganized.
How, then, did Americans choose to reform health care financing and delivery so thoroughly and, apparently, so successfully—at least, so far?
The military, political, and economic cataclysm of World War I swept away czars, kaisers, and sultans. It challenged established ways of thinking, acting, working, and governing.
No such single change evoked the U.S. health care reforms of the past decade.
Rather, the accumulating external and internal threats were responsible.
Cracks in the foundations, a leaking roof, broken windows, widely-disseminated lead paint, termite infestations, and a failed heating plant forced a choice between demolition/replacement of the health care edifice and its thorough rehabilitation.
Some internal threats included the human and financial dislocations that began during the Covid years from 2020 through 2023 but persisted subsequently. These included burnout of many professional caregivers; resignations and retirements; staffing shortages; and revenue growth that was often insufficient to cover growth in expenses.
Other internal threats included suppression of access in hopes of containing cost, the steady melt-down of primary care, the closing of needed rural and urban hospitals, the crisis of unaffordable meds, and the rapidly growing need for long-term care as the U.S. population over age 65 exceeded 20 percent by 2030.
This book posits that reform also stemmed from a series of threats from outside health care— threats from other nations, economic challenges, social problems, and the collision between rising health care costs and an unsustainable federal deficit.
The crisis leading to reform was sparked by the political fights over the size of the federal deficit, the quarter-trillion-dollar yearly rise in health care spending that crowded out other valuable things, and Congress’s decision to freeze spending on Medicare, Medicaid, and ACA subsidies.
The dried brush and logs that caught fire were inside health care itself. Hospitals, doctors, nursing homes, and other caregivers were frightened. So were their workers. Employers paying health care for one-half of Americans feared that hospitals and doctors would try to offset the federal freeze by raising prices paid by insurance companies acting for those employers. Patients were afraid they’d be blocked from obtaining needed care by higher OOPs or premiums, by loss of primary caregivers, by hospital bankruptcies and closings, and by shortages of nursing home beds.
All parties were furious about the wasted health spending that impoverished health care amidst financial plenty.
Payers, caregivers, and patients saw opportunities to do much better by squeezing out fat from existing spending and recycling it as clinical bone and muscle.
But doing that required action to cover all people solidly, contain cost by capping spending, paying caregivers in ways that oblige them—and allow us to trust them—to spend money carefully.
All this obliged abandoning reliance on competitive free markets or traditional government action, mostly reaction—both of which failed health care for decades.
It’s not easy, even with hindsight, to chart the precise path taken to reform health care.
But it’s certain that U.S. health care was spiraling downward both financially and clinically. Our people long deserved medical security. Our nation couldn’t afford to permit health care to continue to act as The Sponge, absorbing money that is badly spent inside health care and is desperately needed for more important purposes outside health care.
And that made it essential to get ready. Ready to act to fix health care when it became politically and financially impossible to continue to paper over health care’s problems.
Comment:
By Don McCanne, M.D.
This new book by Alan Sager is an excellent review of the problems we have with health care, how we got there, and what we can do to ensure that everyone has the health care that they need in a system that is affordable for all. It is invaluable for those who are still not well informed on the policies of health care reform, and it is especially helpful as a review for us old-timers who can stand a refresher course on where we’ve been and where we are going.
The excerpt above, from 2035, obviously is not a precise historical description of the future, but, like the rest of the book, it gives us hope that we really will eventually meet our goal of health care justice for all.
What is really unique about this book is that, of all of the serious problems society faces today, this, almost unbelievably, is the easiest one to fix. Alan Sager explains how.
The Easiest is being posted chapter-by-chapter on this website. You can sign up to receive notices of new chapters, and download them at no charge to share with colleagues and friends who can use them to educate the nation on the fact that there really is hope for effective, sensible, comprehensive health care reform.
There has not been much coming down the pike that offers me more hope about the future of our health care system, but this one does!
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