The health reform debate in Washington often is characterized by two points on the political spectrum:
- Many conservatives want to repeal Obamacare, shifting more responsibility to states and individuals. Proponents argue that a market-based health system would reduce costs through competition among insurers and fewer regulations. Lower costs would make it possible for more people to afford private health insurance, especially if policies with more streamlined benefits could be offered, say supporters of this approach.
- From the left comes growing support for a government-run, single-payer system. One plan gaining notice is “Medicare-for-all.” Under this proposal, the federal government’s health coverage for the elderly and disabled would be expanded over four years to cover all U.S. residents. Medicare’s current benefits – which often are expanded through the purchase of private policies that complement Medicare’s coverage – would be expanded to cover additional services, including dental care, vision services and hearing aids. The cost of Medicare-for-All would be covered through taxes, including new taxes on the wealthiest U.S. taxpayers.
Neither of these approaches has garnered enough congressional support to win passage. In addition to the political challenges of passing major legislation in a deeply divided Congress, there is concern among many policy experts that unless underlying cost drivers are changed, the Republicans’ “repeal-and-replace” approaches to Obamacare and the Democrats’ “Medicare-for-all” merely address symptoms of the U.S. health care crisis.
That doesn’t mean, though, that other ideas for reform aren’t being developed and promoted.
The conservative American Enterprise Institute offered an “Agenda for Reform” based on five core principles:
- Citizens, not government, should control health care.
- Government subsidies should come in the form of defined contribution payments.
- Move power and control from the federal government to individuals, families, and states.
- Suppliers of medical services must have more freedom to innovate and provide better services to patients and consumers.
- Reform must improve the federal fiscal outlook by reducing long-term health obligations.
Proposals dropping the connection between health savings accounts and high-deductible insurance plans, allowing every person to create a tax-free HAS. Included in the plan is a provision that would allow seniors to maintain high HSA balances to pay for nursing home care if needed.
Other ideas come from the National Academy of Medicine, a non-profit group of experts in health and science. Its discussion paper, “Vital Directions for Health and Health Care,” was published earlier this year.
NAM acknowledges that many of the challenges in the U.S. health system stem from how resources are allocated, not how much resources are spent: “(I)t has been estimated that approximately 30 percent (of all U.S. health spending) can be attributed to wasteful or excess costs, including costs associated with unnecessary services, inefficiently delivered services, excess administrative costs, prices that are too high, missed prevention opportunities, and fraud. Resources consumed in this way represent significant opportunity costs both in terms of higher-value care that could be pursued, and in terms of the social, behavioral, and other essential services necessary for effective care and good outcomes.”
Innovations and policies recommended by NAM include the following:
- Making better use of sophisticated information technology to “learn more about disease causes and outcomes, advance precision medicine by creating more precise drug targets, and better predict and prevent disease occurrence or onset.” With this knowledge in hand, treatments can be better tailored to individuals, payments to doctors and other providers can be based on improving outcomes not on how many services are provided and much of the unnecessary health spending could be eliminated. These efforts would be especially advanced if care of an individual were better coordinated through health information technology, from personalized electronic health records to apps that monitor a person’s health status and offer peer support. “All of these technologies are changing the way the health system operates, how individuals interact with the health system and one another, and the data available to monitor and improve health and make care decisions. Technological advances in the health arena have also enabled the rise of telemedicine, which allows patients and clinicians to interact with one another remotely,” according to NAM.
- NAM also recommends spending more money on public health, including investments in understanding and improving the health of communities. “It is increasingly acknowledged that effective measures to improve health status and health outcomes over groups and over time require tending to the conditions and factors that affect individual and population health over the life course, including social, behavioral, and environmental determinants,” said NAM.
Many more organizations – left, right and non-partisan – are offering creative recommendations that address core challenges within the health system and move beyond ideological solutions. The challenge is finding enough common ground in Congress and state legislatures to implement the proposals.