Tomorrow, the House Ways and Means Committee will hold a hearing entitled “Pathways to Universal Coverage.” We applaud House leaders for encouraging serious discussion about the road to universal health coverage. Beyond that, we hope this is the beginning, rather than the end, of a thoughtful discussion of what needs to be done fix our health care system. As important as it is, coverage for all is not the only thing we need to do. Addressing the high cost of the system, improving quality, and promoting better underlying health are also critical. In particular, we need to specifically address the persistent racial disparities in health care and health.
It is also important to place any policy discussion in political context. As we have written previously, to understand that context we need to consider public opinion, stakeholder dynamics and the Congressional balance of power in crafting a path forward.
Consideration of such political dynamics has led one of the witnesses at tomorrow’s hearing — Don Berwick, former CMS administrator and a prominent supporter of Medicare for All —to-write recently “while it is fascinating to think about ‘Medicare for All,’ it is unlikely that the United States will move quickly to fully publicly financed health insurance when the Congress next considers health policy after the 2020 presidential election.”
If Dr. Berwick is right, and we believe he is, how might we proceed in a way that is pragmatic and at the same time consistent with a longer-term vision of a transformed health care system? Below we identify some potential pathways for progress.
To begin with, we should clarify our goals. At Community Catalyst, the high-level goals we embrace for the next phase of health reform are: 1) coverage and affordability; 2) access and quality; 3) addressing the social and economic drivers of health; 4) cost containment; and 5) consumer protection and engagement. These goals require addressing structural injustices and disparities to ensure the health system is centered on people and grounded in their lived experience. There are multiple policy proposals that could be enacted over the moderate short run that would advance these goals while leaving room for continuing discussion on how best to structure health care financing in the long run.
Coverage and Affordability
Congress should encourage states that have not yet done so to expand Medicaid to all low-income adults by providing three years of 100 percent federal financing for any state that takes up the option created by the ACA and by offering additional financial incentives to states that have expanded coverage such as restoring the ACA’s enhanced federal payments for primary care providers in the Medicaid program. Enhanced primary care payments for Medicaid providers in states that have expanded coverage will both provide an additional financial incentive to states and also help ensure there is a robust provider network to provide care for enrollees.
In addition, to expand coverage, Congress should also expand the depth and breadth of financial assistance for those not eligible for employer-sponsored coverage as envisioned in current legislative proposals such as H.R. 1884 and S. 1213. As recent research confirms, expanding coverage helps reduce disparities because people of color make up a disproportionate share of the uninsured and the low-income relative to their populations size.
Access and Quality
In addition to creating a financial incentive to expand Medicaid, enhancing Medicaid payments for primary care is one step for improving access.
Congress should also promote innovative provider models such as dental therapists, doulas, community health workers and peer support workers to address the stubborn and growing mental health and substance use crisis in our country
Congress should expand pay-for-outcomes initiatives that focus on reducing the rates of preventable hospital admissions and emergency room visits. But to ensure that financial incentives to providers to improve quality do not have perverse effects, those payments should be adjusted take into account social needs and the health effects of poverty and discrimination.
A better approach to quality measurement that includes measures like patient confidence that are associated with better outcomes and lower costs is also critical. More generally, a stronger consumer voice is essential in the development of quality measures based on outcomes that matter to consumers.
Finally confronting bias and racism in the patient-provider relationship is a helpful step in tackling discrimination in the health care system. For example, the recent cost containment draft includes training for health professionals on bias and discrimination in the context of maternal health. This promotes a culturally-sensitive caregiving environment that respects patients’ lived experience and increases trust. The current draft proposal from the Senate HELP committee is a start in this direction.
Social and Economic Drivers of Health
There is growing interest in addressing the social determinants of health and acknowledgement that what happens outside the provider’s office (food access, safe and healthy housing, and transportation) influences health outcomes. To strengthen the health care system’s ability to address social determinants, Congress should promote new pilot programs to test how the system addresses social needs; make changes to the Medicaid Health Home program to improve the ability to address consumer’s social needs; and target a portion of new substance use disorders (SUD) funding at supports for low-barrier housing and at comprehensive programs addressing the health and social needs of people at risk of arrest for drug or alcohol misuse.
Cost Containment
Excessive prices are the main reason the U.S. spends more than other countries on health care. We can begin to tackle this problem by limiting the price of drugs and devices to no more than 5 percent above the median price in a comparison group of wealthy countries. This could be done for all payers or could start with the Medicare program, if necessary.
In the context of protecting people against surprise out-of-network bills, we can also place a cap on the amount out-of-network providers can charge in situations where the patient cannot make a meaningful choice of providers. The CBO recently estimated as much as $25 billion savings over 10 years for some of the current proposals.
Consumer Protection and Engagement
There is much to be done to protect patients. A good place to start would be to address the urgent problem of surprise out-of-network medical bills. These bills are a major source of fear and frustration for families. According to a recent Kaiser poll, 67 percent of people fear a major medical bill more than health care deductibles or high drug prices. Eliminating surprise balance billing in situations outside of patient control is a broadly popular idea that provides immediate help to families and does not preclude a shift to more public system in the future.
The House Ways and Means hearing on approaches to universal coverage will, we hope, help lay the groundwork for long-term reform of our health care system. At the same time, we need to place that discussion in a broader political and policy context. The ideas sketched above represent a down-payment on a larger reform agenda to promote coverage, quality and equity that leaves room for a variety of approaches to financing universal coverage.