By CBO’s Single-Payer Health Care Systems Team
Congressional Budget Office, December 2020

Abstract

In this paper, CBO describes the methods it has developed to analyze the federal budgetary costs of proposals for single-payer health care systems that are based on the Medicare fee-for-service program. Five illustrative options show how differences in payment rates, cost sharing, and coverage of long-term services and supports under a single-payer system would affect the federal budget in 2030 and other outcomes. CBO’s projections of national health expenditures under current law are a key basis for the estimates.

CBO projects that federal subsidies for health care in 2030 would increase by amounts ranging from $1.5 trillion to $3.0 trillion under the illustrative single-payer options—compared with federal subsidies in 2030 projected under current law—raising the share of spending on health care financed by the federal government. National health expenditures in 2030 would change by amounts ranging from a decrease of $0.7 trillion to an increase of $0.3 trillion. Lower payment rates for providers and reductions in payers’ administrative spending are the largest factors contributing to the decrease. Increased use of care is the largest factor contributing to the increase.

Health insurance coverage would be nearly universal and out-of-pocket spending on health care would be lower—resulting in increased demand for health care—under the design specifications that CBO analyzed. The supply of health care would increase because of fewer restrictions on patients’ use of health care and on billing, less money and time spent by providers on administrative activities, and providers’ responses to increased demand. The amount of care used would rise, and in that sense, overall access to care would be greater. The increase in demand would exceed the increase in supply, resulting in greater unmet demand than the amount under current law, CBO projects. Those effects on overall access to care and unmet demand would occur simultaneously because people would use more care and would have used even more if it were supplied. The increase in unmet demand would correspond to increased congestion in the health care system—including delays and forgone care—particularly under scenarios with lower cost sharing and lower payment rates.

Working Paper 2020-08 (208 pages):
https://www.cbo.gov…

Blog by CBO Director Phillip Swagel:
https://www.cbo.gov…

Comment:

By Don McCanne, M.D.

As stated in the Abstract, “In this paper, CBO describes the methods it has developed to analyze the federal budgetary costs of proposals for single-payer health care systems that are based on the Medicare fee-for-service program.” Since their reports are provided for Congress, the emphasis is on federal spending rather than on our total national health expenditures. There should be no surprise that they do predict an increase in federal spending since the design of a single payer system does precisely that; it shifts health care spending to the federal government since financing is primarily through the tax system.

They do indicate that total national health expenditures would not change much when compared to our current spending, estimating somewhere between a decrease of $0.7 trillion to an increase of $0.3 trillion. They may have underestimated the savings in that, though they do credit the savings from the reduction of the administrative waste of the private insurers, they do not seem to quantify the very large savings from the reduction of the administrative burden placed on the health care delivery system, though they do acknowledge it as being a source of improved efficiency in the system. A recent systemic review by Christopher Cai, James Kahn and colleagues of twenty economic analyses of single payer indicate that they would all result in long-term net savings.

In indicating that increased demand would produce “increased congestion” in the health care system, they seem to underestimate the ability of the system to self-correct by giving a lower priority to services that are not of much benefit, though queue management is still important in any system.

Some of the experts consulted previously have been criticized for some of their assumptions in their single payer work, and others are experts in the aged and long term care and are not noted for their single payer work. There is also a notable absence of other academics who have long-standing reputations for their credible contributions to the single payer literature. In spite of that, this CBO report is still very useful in that it does what it says it does; it provides a description of CBO’s methods of analyzing single payer and thus would be helpful in understanding future single payer reports from them.

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By Stuart M. Butler
Brookings, December 9, 2020

SUMMARY

The American health system is rife with gaps and inequities. The result is inadequate or no insurance and services for millions of families and unacceptable differences in resources and health conditions related to income, race, and location. Resources are misallocated, the health care infrastructure in many communities is inadequate, and our financial support for health coverage is disjointed and inefficient.

It is time to move towards a health system in America that provides adequate, affordable, and accessible care to all U.S. residents, and that reaches this goal by refining existing programs, correcting the subsidy system, and using the power of federalism. Achieving this goal requires us to:

• Create an effective, grassroots community health system by expanding health clinics, creating other local points of access, focusing on social determinants of health, and addressing gaps in Medicaid.
• Reform the tax treatment of employment-based coverage to create universal subsidies that allow effective choices of coverage in an arrangement that could be described as “Medicare Advantage for All.”
• Use program flexibility and state innovation to create a truly national system with appropriate state variation.

SECTION SUBTITLES OF THIS REPORT

CHALLENGE

LIMITS OF HISTORIC AND EXISTING POLICIES

POLICY RECOMMENDATIONS

• Strategic principles for action.
• Create an effective grassroots population health system
  • Action: Expand community health centers.
  • Action: Make additional access points available.
  • Action: Focus on social determinants.
  • Action: Create an option for non-expansion states.
• Achieve equitable subsidies for insurance: Transition from employer-sponsored insurance to Medicare Advantage for All?
  • Action: Replace the tax exclusion with universal tax credits.
  • Action: Move to Medicare Advantage for All.
  • Create a national system with state variation
  • Action: Make greater use of waivers.

CONCLUSION

A byproduct of the COVID-19 pandemic is a better understanding today of the structural weaknesses of the U.S. health system and a growing appreciation and acceptance of what a reformed system should look like. Still, Americans hesitate to embrace big change in health care, even when they agree on the need for it. Fortunately, reform does not require a wholesale abandonment of the current system and the implacable opposition that likely would be triggered if that were attempted. There are many programs and elements of the current system we can build on and make consistent. Moreover, many of the key ideas discussed in this report have their roots in both political parties, and so, with genuine outreach to leading lawmakers on Capitol Hill, the Biden Administration could achieve bipartisan progress on health reform. Moreover, structural change does not have to come in the form of one giant bill; it can be achieved through a series of bills and administrative actions. Indeed, with a clear, shared vision of the objectives, some bold leadership, and a willingness to build on or remodel some existing parts of today’s system, there is a bipartisan path to an equitable, inclusive, and comprehensive American health system.

https://www.brookings.edu…

Comment:

By Don McCanne, M.D.

Many will remember that it was Stuart Butler who created the Heritage Foundation model that was used as the framework for the Affordable Care Act. It was selected by the Democrats as a model that would have the support of the Republicans because of its conservative bona fides. As it turned out, though the Republicans initially cooperated, it was decided that it was more important to deny President Obama a political success, and so the Republicans fought the measure, requiring the Democrats to make compromises that fell quite short of the equitable, comprehensive reform they intended.

Stuart Butler was not really satisfied with the result either. In the meantime, he wisely moved from the Heritage Foundation which had taken a more reactionary turn, and aligned himself with the moderate Brookings Institution. With the election of Joe Biden as president, an opportunity has arisen to repair the defects in the original ACA legislation, and so Butler presents his views here on what he believes would be “a bipartisan path to an equitable, inclusive, and comprehensive American health system.”

If you believe that reform should be based on making improvements in the Affordable Care Act, as Biden has supported, then the proposal is an effective model of expanding coverage and making it more equitable. It is important to understand it since it is likely that it, or a very similar model, will have strong support by the Biden camp, fulfilling his stated desire to work across the aisle. Just as ACA provided beneficial changes in health care financing, this expansion and correction would as well.

But there are very serious deficiencies in this proposal. Above all, it would leave in place most of the current, highly inefficient, administratively complex and costly health care financing infrastructure which is a major cause of our outrageously high health care costs. In fact, of all of the models of reform, this is perhaps the most expensive, when achieving affordability is one of the primary goals of reform.

Butler points out that his model would be bipartisan because it includes specific policies that come from each side of the political spectrum and some policies on which there is mutual agreement. Although the policies expanding health care justice would certainly be welcome, other policies that further privatize the system, such as a move towards private Medicare Advantage for All, should be rejected since private plans have been responsible for many of the injustices in health care today.

We’ve stated several times before that we need to get the policy right and then change the politics to enable enactment and implementation of those policies. Butler has it backwards. He is trying to clear the political hurdles by accepting flawed policies that would appeal to the ideological preferences of those on the right, assuming that the left will accept any compromises as long as reform is advanced, as they did with ACA.

If we want the most affordable program that is truly universal, comprehensive, and especially is equitable, then we need to enact a well designed, single payer, improved Medicare for All, but we’ll need to travel the rough political road of convincing Joe Biden that Medicare for All is what we want and need.

In the meantime, try to understand Stuart Butler’s proposal so we can explain to President Biden and everyone else why we do not want to go that route.

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American Hospital Association, December 2020

Introduction

Health care coverage has never been more important as the nation battles the COVID-19 pandemic – now and for the foreseeable future. Two-thirds of the population relies on the private sector for health insurance coverage and thus access to health care. While private health insurance coverage has long served as the backbone of our national system, that very coverage and the security it offers millions of Americans is eroding at an alarming pace. Health care insurance was originally designed to be a straightforward financial agreement between a health plan and a consumer: the consumer paid a premium in exchange for coverage of a set of health care services offered by a certain group of providers. If disputes arose, consumers could expect that adjudication of the claim would follow a fair, efficient, and transparent process. This agreement, underpinning America’s system of health insurance for decades, is beginning to slip away in some markets across the country, and the COVID-19 public health emergency is further shining light on its erosion.

Not only are private health insurance plans the dominant source of health care coverage for most Americans, but employers, as well as the Medicare and Medicaid programs, rely on private health plans to provide or administer their health benefits. Approximately one-third of Medicare beneficiaries are enrolled in a private Medicare Advantage health plan, and nearly all states enroll some or all of their beneficiaries into Medicaid managed care plans.

Coverage through these plans is eroding as some health insurers restrict access to health care services by abusing utilization management programs and changing health plan rules in the middle of a contract year. For example, prior authorization, one of the most widely used utilization management tools, is designed to help patients obtain the right care in the right place. Insurers use prior authorization to ensure that providers order care that is consistent with clinical guidelines and protocols, as well as to confirm that such care is covered by the patient’s plan. This tool was designed to primarily help guide (and monitor) providers’ decision-making around treatments that are new, particularly high cost, or that have a history of questionable use. However, some plans are now applying prior authorization to a wide range of services, including those for which the treatment protocol has remained the same for decades and there is no evidence of abuse.

Unjustified use of utilization management tools like prior authorization has a number of negative implications for patients and the health care system. Patients are often blindsided by denials and can face unexpected medical bills as a result. The extensive approval process that doctors and nurses must go through adds billions of wasted dollars to the health care system and contributes to clinician burnout.

Evidence of the negative impact of these practices is mounting. The Department of Health & Human Services Office of the Inspector General (OIG) warned in a September 2018 report that high rates of Medicare Advantage (MA) health plan payment denials and prior authorization delays could negatively impact patients’ access to care. In 2019, a federal court found that the largest commercial insurer in the United States was abrogating the entire point of health insurance by systematically denying medically necessary, covered behavioral health services for financial reasons. It is worthy of note that in response to COVID-19, many health insurers, including at the urging of government, scaled back the use of many of these tactics precisely because they create barriers to care. State governments, as the primary regulators of insurance, have also taken action. For example, New York State passed a number of insurer accountability measures at the beginning of the COVID-19 to help ensure patient access to care and to remove unnecessary burdens on providers on the front lines.

In 2019, the American Hospital Association (AHA) fielded a survey to better understand the impacts of health plan utilization management practices on patients and providers. More than 200 hospitals and health systems responded. Their data was supplemented with interviews and group discussions with several hundred additional hospital and health system executives. The following report documents our findings related specifically to prior authorization and payment delays and denials. While these findings pre-date the COVID-19 public health emergency, they remain not only relevant but serve to underscore the urgency to address these issues as hospitals remain on the front line of care for COVID-19 patients. The report offers policymakers solutions to reduce the risk and burden of these programs while still enabling health insurance plans to compete on quality, benefit package design, provider networks, and other important aspects of coverage.

(This nine page report then discusses problems with interacting with the private commercial insurers, especially with prior authorization and with reimbursement delays and denials. They then discuss their view of potential policy solutions.)

Conclusion

Certain health plan practices threaten patient access to care and drive excessive administrative costs and burden in the health care system. While these concerns pre-date COVID-19, the current public health emergency both highlights and demands immediate action to protect patients and providers. Regulators should increase their oversight of health plans and implement a comprehensive simplification agenda, beginning with streamlining prior authorization requirements and processes, as well as monitoring for abusive payment delays and denials. These efforts will go a long way to addressing unnecessary costs in the system and allow for a more rational, navigable health system for patients.

https://www.aha.org…

AHA Comments on “Medicare for All”

By Tom Nickels, Executive Vice President AHA
American Hospital Association, February 27, 2019

America’s hospitals and health systems are working with policymakers to help expand coverage and improve affordability for all Americans. However, we are opposed to “Medicare for All,” as it would impede our shared goals.

To start, a one-size-fits-all approach would disrupt coverage for the more than 180 million Americans who are covered by employer-sponsored health plans. That coverage, and plans sold on the marketplaces, offer benefits that Medicare doesn’t. Importantly, enrollees in these plans are protected from catastrophic costs.

Further, the government can be an unreliable business partner, as we just witnessed with the longest partial government shutdown in our nation’s history. Congress also has a history of slashing provider payments for government health programs to meet its budgetary goals.

Additionally, important delivery system reforms to improve care, enhance quality and reduce costs would no longer be a priority once government controls all payments to providers.

Finally, public programs like Medicare and Medicaid reimburse providers less than the cost of delivering care for patients, which exacerbates access problems.

The AHA believes there is a better alternative to help all Americans access health coverage – one built on fixing our existing system rather than ripping it apart and starting from scratch. In addition to expanding Medicaid in the remaining non-expansion states, we support strengthening the marketplaces to improve their stability and affordability, and increasing enrollment efforts to connect people to coverage.

https://www.aha.org…

Comment:

By Don McCanne, M.D.

It is no surprise that members of the American Hospital Association (AHA) recognize the abuses of the private commercial insurance plans since they have to deal with them on a daily or even hourly basis. Although this report focuses on prior authorization and payment abuses, the extensive other problems, especially private insurers being the primary source and cause of the hundreds of billions of dollars in administrative waste in health care financing, should lead us to the conclusion that this industry should be eliminated. But what does AHA say?

In slamming the private commercial insurance industry, including private employer-sponsored plans, AHA certainly recognizes the source of these problems. But what about public insurance programs such as Medicare and Medicaid? AHA’s expressed complaint in today’s report is not with government administered plans but rather with private Medicare Advantage and the private Medicaid managed care plans.

AHA’s proposed solutions for prior authorization and payment abuses would leave in place our very expensive, fragmented and highly dysfunctional health care financing system, and would only tweak some of the administrative complexities. If the corrective measures would reduce the insurers’ net revenue, being masters of innovation, they would find other means of milking more out of the system. It is in their nature, and they will not change.

The hospitals would clearly benefit from a well designed, single payer, improved version of Medicare that covered everyone, so why do they not support it? The statement from AHA advances specious arguments such as the trite contention that “a one-size-fits-all approach would disrupt coverage.” Actually we should want the current coverage to be disrupted since it is the source of much of the dysfunction with health care financing.

Medicare does need to be improved and that would occur with enactment of Medicare for All, but the only real complaint AHA has is that the reimbursement rates are low. With the PNHP single payer model, hospital payment would be converted to global budgets, much like fire departments. The government would have to budget enough funds to be certain that the capacity of the system is adequate and that distribution is appropriate for the needs.

AHA and the AMA should concede that the health care system should be designed and financed to meet the health care needs of the patients. That means that the system needs to be adequate and then the physicians and hospitals will do just fine. And just think how pleasant the task will be when the system is finally cleared of all of the administrative garbage dumped on us by the private insurers.

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By Emilie Raguso
Berkeleyside, December 5, 2020

Bob Hess Sr., an iconic figure in the world of Bay Area horse racing, died Saturday morning after being diagnosed in mid-November with COVID-19, Golden Gate Fields racetrack announced.

Hess came down with COVID-19 amid a widespread outbreak at Golden Gate Fields that initially resulted in more than 200 coronavirus cases. But he refused to blame anyone for getting sick and said he was just focused on getting well. (A photograph of Bob with his wife Maria and their horse Maggie’s Magic showed both of them wearing their masks.)

Hess is survived by Maria, his wife of 56 years, and their four children, horse trainer Bob Jr., Howie, Erica and Anna.

When advised Hess had passed away this morning, jockey Abel Cedillo was moved to tears.

“When I was riding up north, he was like a second father to me,” said Cedillo, a Guatemalan native who was the leading rider at Del Mar’s recently concluded Bing Crosby Meeting. “I had so much respect for him. I’m shocked. I’m going to really miss him.”

https://www.berkeleyside.com…

Trump, still infectious, back at White House — without mask

By Zeke Miller, Jill Colvin and Aamer Madhani
AP, October 5, 2020

President Donald Trump staged a dramatic return to the White House Monday night after leaving the military hospital where he was receiving an unprecedented level of care for COVID-19. He immediately ignited a new controversy by declaring that despite his illness the nation should not fear the virus that has killed more than 210,000 Americans — and then he entered the White House without a protective mask.

Trump’s message alarmed infectious disease experts and suggested the president’s own illness had not caused him to rethink his often-cavalier attitude toward the disease, which has also infected the first lady and several White House aides, including new cases revealed Monday.

He entered the White House, where aides were visible milling about the Blue Room, without wearing a face covering.

The president left Walter Reed National Military Medical Center, where his doctor, Navy Cmdr. Sean Conley, said earlier Monday that the president remains contagious and would not be fully “out of the woods” for another week.

https://apnews.com…

Elevating Fringe Theories, Ron Johnson Questions Virus Science

By Catie Edmondson and Nicholas Fandos
The New York Times, December 7, 2020

In choosing a slate of doctors to testify about coronavirus treatments before his committee on Tuesday, Senator Ron Johnson has assembled a cast of witnesses who question much of the public health consensus about the virus.

Mr. Johnson has suggested that the dangers of the coronavirus have been overblown and excessively regulated.

Mr. Johnson’s lead witness on Tuesday, Dr. Jane M. Orient, has cast doubts on coronavirus vaccines and has pushed for the use of hydroxychloroquine, an antimalarial drug pushed by Mr. Trump, as a treatment. She helps run a group that believes government vaccine mandates violate human rights.

Another, the Washington cardiologist Ramin Oskoui, said on Fox News last month that it was “settled science” that “social distancing doesn’t work, quarantining doesn’t work, masks don’t work.” On the contrary, it is settled science that all three are effective in limiting the spread of the virus.

https://www.nytimes.com…

The Outlook for Health Reform in 2021

By Grace-Marie Turner, Galen Institute
Benjamin Rush Institute, November 30, 2020

Grace-Marie Turner: I really do think that there is so much politicization in academia in medical schools. A friend of mine, Dr. Sally Satel who works with the American Enterprise Institute, actually wrote a book in the early two thousands called PC MD, the political correctness in medicine that really corrupts the science of truth and what physicians need to know. Masks are a perfect example, you know, data shows, and this broad study in Denmark recently showed that masks – it doesn’t make a difference whether you’re wearing masks or not in the infection rate. The politicians still insist that we’re going to have to wear a mask because they really don’t know what else to do. So I think that the real risk is that the more power that we give government over decisions, more academia over decisions, the less power doctors and patients and real science will have over really guiding change and reform in the right way. So, yes, does climate change have a role in medical school? Not sure, but I bet there’s a lot of funding behind that. I want physicians as scientists to be able to make the right decisions for their patients, not a politically directed decision.

At 52:20 of video:
https://www.youtube.com…

Comment:

By Don McCanne, M.D.

Bob Hess was a close friend of one of our sons. Sandy and I previously spent a weekend with him and his family, and what a wonderful person he was – a very colorful and caring person – and, of course, his stories about the horse race culture were spellbinding.

Bob said that he refused to blame anyone for him getting sick, but our son, overwhelmed with grief, does cast blame and does so in language laced with four letter words. Hints of where he casts blame are found in the positions expressed by President Donald Trump, Senator Ron Johnson, and Galen Institute’s Grace-Marie Turner. The guidance that people like them are providing to the nation has caused massive, reckless disregard for the health of victims exposed by individuals who believe that the recommended precautions are somehow conspiratorial and that, as a result, people are being deprived of their freedom to associate freely with whomever, wherever and however they felt inclined to do so.

Our son stated that our leaders who are setting an example by going maskless as a right and as a political statement amounts to negligent homicide, and I agree with him. So far, over 282,000 people have died, and many more will – a number compounded by the uncaring leadership that abandoned public health science.

May the memory of Bob motivate more of us to follow the real public health science and move us through this pandemic much more rapidly with the least grief possible. I think Bob would want that. He was too nice of a guy to think otherwise.

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By Sheryl Gay Stolberg and Michael D. Shear
The New York Times, December 6, 2020

President-elect Joseph R. Biden Jr. has selected Xavier Becerra, the Democratic attorney general of California, as his nominee for secretary of health and human services, tapping a former congressman who would be the first Latino to run the department as it battles the surging coronavirus pandemic.

An outspoken advocate of improved health care access, Mr. Becerra said in 2017 that he would “absolutely” support Medicare for all, a proposal for government-run health care that Mr. Biden has explicitly rejected. A source familiar with the selection said Mr. Becerra would support the president-elect’s call for strengthening and preserving the A.C.A. and would not be pushing Medicare for all while in office.

https://www.nytimes.com…

Comment:

By Don McCanne, M.D.

Supporters of single payer Medicare for All should be pleased that President-elect Biden has selected Xavier Becerra as his nominee for HHS Secretary since Becerra has been a long time supporter of single payer, having repeatedly been a co-sponsor of John Conyers’ H.R. 676 Medicare for All Act.

At the same time, we should understand why Becerra is willing to agree to honor Biden’s campaign promise to reject Medicare for All. Becerra had a choice to do all he can to support health care justice short of single payer reform, or to reject the offer, leaving the opportunity for someone else who would likely be more friendly with the medical-industrial complex, including the private insurers. There is no way that Becerra, or anyone else, could have convinced Biden to permit single payer advocacy by his administration’s HHS Secretary.

Becerra’s most urgent task will be, with other members of the Biden team, to quash the COVID-19 pandemic. At the same time, he will have to supervise the reversal of the harmful policies implemented by Trumps’ team that wreaked so much havoc at HHS, significantly impairing the government’s role in ensuring health care justice in America. He will be buried in essential work that must be done immediately, so it is not the time to spin his wheels trying to make Biden change his mind on this one issue.

It is not clear that efforts will begin soon on enacting a public option, but it is unlikely considering that they have their hands full. Nevertheless, if and when the public option process begins, the private insurance industry will be working behind the scenes to be certain that the government will not produce a product that can successfully compete with the private insurance industry as long as we perpetuate our fragmented, dysfunctional financing infrastructure. There is absolutely no chance that a public option would be created that has all of the features of the PNHP single payer model and still would cost less than the private plans. Yet the risk is that a mediocre plan could be used to convince the public that the government role has been fulfilled and that Medicare for All should be dismissed permanently from consideration, especially when they find out how mediocre a government plan can be, while remaining oblivious to the sabotage.

At this point, it is not Becerra who has to be convinced that single payer Medicare for All is a much better approach for the intermediate and long term. It is Joe Biden that needs convincing.

So that brings it back to us.

We need to step up the education of our colleagues and the public at large since they still do not understand the vast superiority of the single payer model and still believe that everyone should be offered the option of private insurance.

We need to work with others in the social justice movement, bringing us together in coalition activities that will be effective in delivering the message.

We need to build a grassroots movement that will reach the very high political threshold of “make me do it.” Joe Biden is not asking us to make him do it; we need to change the politics so that he will.

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By Arush Lal, M.Sc.; Ngozi A Erondu, Ph.D.; David L Heymann, M.D.; Githinji Gitahi, M.D.; Robert Yates, M.B.A.
The Lancet, December 1, 2020

Summary

The COVID-19 pandemic has placed enormous strain on countries around the world, exposing long-standing gaps in public health and exacerbating chronic inequities. Although research and analyses have attempted to draw important lessons on how to strengthen pandemic preparedness and response, few have examined the effect that fragmented governance for health has had on effectively mitigating the crisis. By assessing the ability of health systems to manage COVID-19 from the perspective of two key approaches to global health policy—global health security and universal health coverage—important lessons can be drawn for how to align varied priorities and objectives in strengthening health systems. This Health Policy paper compares three types of health systems (ie, with stronger investments in global health security, stronger investments in universal health coverage, and integrated investments in global health security and universal health coverage) in their response to the ongoing COVID-19 pandemic and synthesises four essential recommendations (ie, integration, financing, resilience, and equity) to reimagine governance, policies, and investments for better health towards a more sustainable future.

Introduction

National responses to COVID-19 have varied greatly, from swift and proactive at best to haphazard and negligent at worst. That countries have managed the pandemic differently is expected, but COVID-19 has pushed all health systems to their limits, exposing severe gaps in public health infrastructure, even in nations once lauded as the gold standard for readiness. Although much has been discussed about how countries could have been better prepared, these analyses have largely missed a focus on how fragmented governance for health and the resulting silos in financing of health systems (ie, vertical funding streams towards single disease categories, independence of tertiary care from primary care, and differences in domestic health priorities vs global health priorities) continue to hamper response efforts. Analysing the spread of COVID-19 from the perspective of global health security (GHS) and universal health coverage (UHC) offers a useful opportunity to uncover blind spots in fostering health-system resilience moving forward. In this Health Policy paper, we seek to understand how health systems that are heavily influenced by either GHS or UHC policies have initially fared with the shock of the ongoing COVID-19 pandemic, and we conclude with four key recommendations to redesign health systems for a sustainable future.

Health systems with stronger investments in GHS capacities

Despite the USA receiving top ratings for pandemic preparedness in the Global Health Security Index, it has, to date, reported the world’s highest number of COVID-19 cases and deaths. Although the country has an impressive array of public and private laboratories, innovative pharmaceutical and technology companies, and a national public health institute with high capacity, the USA ultimately relies on a greatly fragmented health-care system. Each state funds and operates its own systems for public health and surveillance, and the nation has been reluctant to build a unified health system that is publicly funded. This absence of clear coordination, a crucial IHR (International Health Regulations) core capacity, has so far hindered the country’s ability to accurately estimate and forecast the effect of COVID-19, resulting in delayed response activities, including testing and contact tracing. Additionally, the scarcity of centralised funding has led to chronic misuse and underuse of human and financial resources. Finally, high rates of underinsurance could disincentivise health-care use and discourage citizens from seeking emergency care, leading to untreated chronic diseases, reducing capacity for syndromic surveillance, and undermining overall trust in public services; thus further accelerating the effect of COVID-19. The USA is one of the most prominent examples, showing that reliance on traditional GHS capacities to provide an accurate assessment of health-system readiness does not account for the effect of incoherent coordination and inadequate UHC and political economy during health emergencies.

Health systems that align GHS and UHC investments

Although not mutually exclusive, GHS and UHC tend to have different policies in practice. Thus far, countries with policies that are closely aligned with both frameworks have generally fared better and might be better equipped to recover after COVID-19 compared with nations with health systems that are not aligned to both frameworks, which could struggle to cope with challenges in the long term. Importantly, health systems that successfully integrated GHS core capacities with PHC services have been particularly effective at mitigating the effects of COVID-19.

Reimagining governance, policies, and investments for global health

Although breaking the cycle of panic and neglect, which is necessary for sustained GHS, might be unlikely, re-envisioning UHC as the foundation for solidarity and action, including for health security and healthy societies, offers a necessary path forward in the world after COVID-19. A system with programmes for social protection, cost-effective PHC, inclusive leadership, and adequate public financing can guarantee quality services for all, especially in fragile contexts where poverty, overcrowded housing, and inadequate resources make communities most susceptible. In the recovery from COVID-19, economic fallout and public fear might push countries to favour isolationist approaches to health, favouring privatised health care and quick fixes to provide the illusion of health security. Donors and advocates should be wary of overly securitised or neoliberal solutions that have long restricted both GHS and UHC, instead backing truly universal, publicly financed, and country-owned health systems that promote health equity and upstream determinants of health to leave no-one behind. This expanded implementation of GHS capacities that are embedded and delivered through UHC can be developed along four core recommendations: integration, financing, resilience, and equity.

• Integration: build robust GHS capacities into comprehensive UHC systems
• Financing: break narrow funding pathways that prevent unified health systems
• Resilience: develop and assess health-system resilience
• Equity: apply a rights-based approach as the necessary foundation for health systems

From the Conclusion

With the effects of additional sociopolitical factors, such as protracted crises, race, gender, climate change, economic status, and differing social contracts between citizens and their governments, the influence of competing priorities in the governance for global health should be integrated into traditional preparedness and response guidance. A reimagined framework for global health that prioritises health-system integration across UHC and GHS domains, innovative and unified health financing, cross-sector resilience indicators, and equity as a core value offers a necessary path ahead. National authorities developing health-system priorities and funders, who control expenditure, agenda setting, and prioritisation of investment, cannot continue business as usual. To rebuild a more sustainable future after COVID-19, embedding the core capacities of GHS into holistic, publicly financed UHC systems is the clear next step forward. We cannot keep jumping from one epidemic to the next while ignoring the political will that is required to invest in the foundations of health for all. In the end, truly universal, comprehensive health systems in all countries, which have integrated core capacities for public health and are aligned across all levels of governance, will be our strongest defence against the next great pandemic.

https://www.thelancet.com…

Comment:

By Don McCanne, M.D.

In response to the enormous strain placed on countries by the COVID-19 pandemic, the authors recommend rectifying the misalignment between global health security and universal health coverage.

How does this apply to the greatest health care system on earth, er, well, the most expensive one? Our current commitment to global health security is perhaps best represented by our withdrawal from the World Health Organization just at the time or our greatest need – not much of a commitment. Also, of all wealthy nations, ours is the only one that is not fully committed to universal health coverage.

Next month we will have a new administration. President-elect Joe Biden has told us that we will immediately rejoin the WHO, obviously a very important first step toward improving global health security, though much more will need to be done.

Regarding universal health coverage, Biden has already rejected the most efficient and effective model that would achieve that goal – single payer improved Medicare for All. Although he proposes policy patches to our current system, those measures are not adequate to correct the severe dysfunctions in our financing system and will still leave an unacceptable number of us without adequate coverage.

The authors state that we need “a reimagined framework for global health that prioritises health-system integration across UHC and GHS domains, innovative and unified health financing, cross-sector resilience indicators, and equity as a core value.” With our wealth and our renewed pledge for cooperative leadership in the world, the United States should lead the way.

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