A Better Health Care System for All

America spends about twice as much on our health care system today as other wealthy nations, yet we do not see better health outcomes and have alarming inequality in access to care. That has all been laid bare during the pandemic, and if this status quo isn’t a call to action for change, I don’t know what is.

I have a classic song and a great book to set the theme for this prong of the “We’re Better Than This” platform: Doctor My Eyes by Jackson Browne is the song, and the book is Being Mortal by Atul Gawande.

The first step to a better system is to change the default scenario when someone does not have health insurance through their employer or one of the government programs. Unless someone uses the “Obamacare” marketplace to find a plan, that default today is no coverage, which is the reality for millions of Americans today. That not only is bad for their health, it is bad for our community health (the pandemic being a stark example) and becomes a hidden tax on the rest of us when we end up paying for inefficient emergency care for people with more serious medical issues that have gone untreated.

We should change that default to people having a new public option for coverage that is paid for through their taxes. (More on the source for the payments next week in the tax and revenue prong of this platform). My proposed new system would give everyone a tax credit (say $6,000 per individual) that rises with the rate of inflation; people could use the credit to buy individual coverage or their employers could use it to provide that coverage, but otherwise people would automatically have the public coverage option.

We then could set some broad limits on the types of plans that could be offered in the private marketplace, starting with a requirement that only modest copays or deductibles would be permitted, offering additional bonus payments for plans that have good overall health outcomes for their participants, and meting out financial penalties for plans that have particularly bad outcomes. Market forces could then go to work to encourage plans to offer the most efficient care to reach good health outcomes.

For the public option, rather than paying “fee for service” that rewards more care rather than better outcomes, the government plans would pay set amounts to health networks to cover all care and would be permitted to negotiate drug prices too. Additional subsidies could ensure care is available for rural and underserved populations. And as with the private market plans, there could be additional bonus payments to the health networks for good health outcomes, who could offer “nudge” payments to patients to encourage them to adopt healthy lifestyles and follow preventative care recommendations.

Both the public and private plans would cover mental health, vision, and dental care on an equal basis as well, as we know these are critical to overall good health.

Medicare could remain a distinct program, but it should follow the same principles to make it more cost-effective and predictable for both patients and providers.

The VA could work similarly as well, with VA hospitals focusing on unique needs and medical issues for those who have served our country but veterans also getting the same option everyone else would have to get private coverage for their other medical needs.  

Sound like pie in the sky that we could afford all this? Remember, we already are spending twice as much on our system as other wealthy countries, including an outsize share on administrative costs driven by the overly complex and balkanized current system.

While there would be new costs that would require some new revenue, the administrative savings alone would pay for much of the tab. Administrative employees now handling those tasks could shift to being care coordinators who help make sure people are following up on preventive care and treatment regimens, which also would lower costs.

Stopping the current practice of rewarding unnecessary care is another big area of savings here, bigger than we might imagine if we start rewarding good health outcomes instead. And finally, we can save significant amounts if we follow a “death with dignity’ approach for people who already are terminally ill rather than using (and paying for) extraordinary measures in all instances without a showing of improved health and wellbeing.

A supplemental insurance market could offer optional coverage for discretionary, experimental, and/or extraordinary care expenses. And nonprofit and charity providers could focus on research and providing experimental care.

I recognize this would be a huge amount of change in the market, and I recommend phasing it in gradually over a period of several years so the market has time to adjust. But there is no doubt we can and must do better for the amount we are spending on our health care system with so much inequality, as other countries already are showing us.

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