A Diagnosis for American Health Care
Last Friday afternoon, as Republican senators began pushing toward a last-ditch vote to repeal the Affordable Care Act (ACA), and as Senator Bernie Sanders was making news with his proposed “Medicare for All” bill, a dozen health-care experts gathered at the Radcliffe Institute to discuss what one audience member called “this mess we’re in.”
Focused on the “policies and politics” of the American health system, the symposium, titled “It Depends on What State You’re In,” probed the successes and failures of Obamacare, the status of Medicare and Medicaid, international alternatives to the American system, and the myriad possible meanings of “single-payer” health coverage. “Single-payer has no single meaning,” said Freed professor of government Daniel Carpenter, who’d kicked off the symposium by noting a recent momentum shift toward universal, government-sponsored health insurance. “And exactly how it is designed, which means exactly how it is politically shaped, means everything.”
One point was unanimous throughout the afternoon: the current American system of health care remains deeply inefficient, and in its inequalities, immoral. In one presentation after another, versions of the same basic diagrams kept appearing on the display screen above the podium: a chart, or sometimes a graph, showing how the United States stacks up against other wealthy, industrialized nations. The persistent answer: not well. It’s unequal and expensive, with rising costs that far outstrip those found elsewhere around the globe. “We know Americans don’t get the same value for our dollar,” said Georges C. Benjamin, a former emergency physician and executive director of the American Public Health Association. “Americans pay more for health care than other industrialized nations, and we die sooner.”
William Hsiao, Li research professor of economics at the Harvard Chan School of Public Health (HSPH), observed that the United States is “the only affluent country in the world to build a system around the free market”—a choice he diagnosed as the root of its health-care problems. Michael Lighty, director of public policy for National Nurses United and the California Nurses Association, echoed that point: “What we’ve seen is the transformation from a care-giving profession to a health-care industry based on revenue and profit,” he said. “Quality is skewed toward the top.” Similarly, Hsiao added, parts of the country “have the best quality of care in the world.” But, “if you go to the Mississippi Delta, if you go to Idaho, you see third-world medicine there in practice.”
To some extent, Obamacare, which has added 23 million Americans to insurance rolls, helped ameliorate the inequality in access—especially in the 31 states, plus Washington, D.C., that accepted Medicaid expansion. Associate professor of health policy and economics Benjamin Sommers cited surveys showing that the number of Americans who say they can’t get the care they need because of money has dropped. The American Public Health Association’s Georges Benjamin pointed to less-dicussed ACA initiatives that are important to community health, most particularly the Prevention and Public Health Prevention Fund, a massive investment in innovations and infrastructure to improve public health, funding everything from Alzheimer’s disease support to suicide prevention to lead-poisoning prevention to increasing the capacity for states and municipalities to respond to infectious outbreaks.
The ACA’s Medicaid expansion has allowed some providors to do more for patients. Kate Walsh, president and CEO of the Boston Medical Center, a nonprofit hospital with a large proportion of low-income patients, talked about several ancillary programs the hospital now provides for families on Medicaid: addiction therapies, a food pantry that operates by prescription, a jump-rope program for children at risk of obesity, another that brings accountants on site to help families do their taxes while their children are being seen by pediatricians. “The health-care industry has to embrace the Medicaid program,” Walsh said. “Medicaid is the most important insurance plan, I would submit, in our country today. It covers more than half of births; it pays for 70 percent of long-term-care treatments. So we have got to get over our ambivalence about this.” She acknowledged the problems of Medicaid’s “fee-for-care-service” structure, which reiumburses physicians and hospitals at sometimes very low rates—“I can get as frustrated as any hospital executive any day of the week about the challenges of living within the Medicaid envelope,” she said—but those problems can and ought to be overcome, she argued. “We have such an intergenerational responsibility to get this program right.”
The ACA’s stumbles have been much publicized, and the symposium’s speakers noted a few of them: higher premiums for a fraction of Americans, instability in some health insurance marketplaces, deductibles that can be thousands of dollars (though low-income Americans receive some subsidies to help cover that). In addition, 19 states’ rejection of Obamacare’s Medicaid expansion prevented the program from operating as designed. Sommers noted the three to four million people in those states who have no affordable options at all for health insurance. “If you are a single parent in Texas, your income has to be under $6,000 per year to qualify for Medicaid,” he said. “If you have no children in your home, it does not matter how poor you are; unless you have a disability, you won’t qualify for Medicaid.” Also significant: Obamacare was never intended as a universal coverage bill, and even if it had been fully implemented and working as designed, Sommers observed, an estimated 20 million to 25 million people would still not have coverage. “You might argue that was not a dysfunction of the ACA but a dysfunction of the political system, or what it was able to produce,” he said.
MIT political scientist Andrea Louise Campbell ’88 talked about the Catch-22 built into the Obamacare Medicaid expansion: some states, in an effort to ease the stigma of Medicaid, called their programs something else—TennCare in Tennessee, Kynect in Kentucky. “Even here in Massachusetts, it’s MassHealth, right?” Campbell said. The move worked. Studies show that getting insurance through one of these programs does lower stigma, but patients are also less likely to recognize they receive Medicaid, and therefore are less mobilized to act on legislative threats to the ACA.
The question of just how to improve—or overhaul—the system was a harder one for panelists to answer. Short-term fixes were obvious: shore up the health-care exchanges and boost outreach for enrollment (that outreach has recently been cut under the Trump administration). Maintain funding for the ACA’s community-health initiatives.
Longer term, the answers grow more diffuse. Lighty, from the national and California nurses associations, spoke about SB 562, the proposed legislation that would establish single-payer health care in California. “We believe we have to start at the state level because federalism is at the heart of the American system. But if we can prove this type of program works in a state like California, especially—which has the resources of a nation—then we can do it federally.”
Hsiao, who has helped design and reform national health care systems in nine countries, including Taiwan, Sweden, China, and South Africa, said he doesn’t think the United States as a whole is ready for single-payer coverage just yet, but that day may be coming. When Sommers asked the group to estimate what health-care reforms the country might feasibly be able to adopt in the next decade, Hsiao, after describing some of the steep hurdles to single-payer—including design decisions not yet figured out and, perhaps especially, the powerful opposition of vested interests—argued that the United States is only at the beginning of a single-payer push, which will take another several years to reach fruition. By the 2024 presidential election, but probably not before then, he said, Americans will see a markedly different kind of health-care discussion: the legislative sausage-making negotiations that lead to a working policy for which the broad outlines are already agreed on. “That’s when single-payer is really going to be debated in a really serous way, and moving towards real, practical, viable, and politically acceptable.”