Complexity in the US Health Care System Is the Enemy of Access and Affordability, JAMA Forum, Oct. 26, 2023, by Larry Levitt and Drew Altman
Lack of insurance coverage, high costs, and poor outcomes are well-documented problems in the US health care system, and policies to address them have been hotly debated for decades. However, complexity is another under-appreciated problem that hinders access and affordability.
Almost 6 in 10 people with insurance reported a problem with using their health insurance during the past year (2022). The share increases to two-thirds of people in fair or poor health, three-fourths for those who need mental health services, and almost 8 in 10 for people who use the health system the most. The result is that many delay or skip care or accumulate bills they cannot afford.
The reality is that many people are hopelessly confused by how their insurance works. In Medicare, beneficiaries can now choose from an average of 43 private Medicare Advantage plans, and during open enrollment season, the airwaves are flooded with ads that may do more to confuse rather than illuminate. And people getting ACA coverage through healthcare.gov have a choice of more than 200 plan options on average. The complexity of too many choices can also lead to paralysis on the part of consumers.
Yet, any push for health care simplification inevitably clashes with commercial interests. The system is structured to simultaneously maximize profits, control costs, and serve customers, which are competing goals that add to the challenge of simplifying it.
Comment:
By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.
Although Health Justice Monitor commented on this article a year ago, political developments have not only failed to provide significant improvement in our expensive but underperforming health care system, it appears that the malfunctioning of our system will only become worse.
We have been increasingly reliant on private insurers as demonstrated by the increase in conversion of traditional Medicare to private Medicare Advantage plans and the greater reliance on commercial plans through the Affordable Care Act. So we are spending ever more of our health care dollars on an industry with a mission that places a higher priority on diverting health care dollars to private investors instead of directing all of those dollars to achieving comprehensive health care for everyone.
We have an abundance of health policy research that demonstrates that the defective private insurance model increases costs and decreases access to care. It should be eliminated and replaced by a public single payer program that would, by design, not only provide health care for absolutely everyone, but also control costs while improving the allocation of health care dollars. That model would be similar to traditional Medicare except that it would offer more comprehensive benefits, eliminate cost sharing that currently causes financial hardship, assure free choice of providers and facilities, and equitably finance via progressive taxes which would be affordable for everyone without materially diminishing the lifestyles of the wealthy despite their paying more (they can afford to!).
In our recent presidential election, one of the major parties emphasized neoliberal policies which eliminated any consideration of the superior single payer model, instead supporting small incremental changes which would have negligible impact in healing our sick health care system. The other major party vaguely promised system improvement but hinted major cuts in public spending. They also selected individuals as likely heads of HHS and CMS who would shred the program that we have at a cost of lives, health, and worse financial hardship for patients.
Wouldn’t it be better set aside politics, and instead adopt policies that provide definitive solutions to the problems of high personal health care costs and financially squeezed providers? We have ample examples from countries of varied political leanings of how to use funds well.
Shouldn’t we encourage our legislators, all of them, to join together to approve a system that would work so well for everyone? Now that we have an incoming president who would like to take personal credit for radically redirecting government to serve the public, maybe we have a chance.
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