The idea of radically altering health care—one-sixth of our national economy—either to the left or the right—is something that should make everyone pause. This is an area filled with the potential for unintended consequences. That said, while the Patient Protection and Affordable Care Act provided health care to 20 million people who did not have it before (and providing care, not taking it away, is the proper goal of any health care legislation), we have more work to do to make the system cover everyone at less cost. Remember calling for that, Mr. Trump?
I read a few years back about France's health-care system. It was described as the best in the world. (There are many ways to measure this to get different results.) It was described also as a public-private system, which reminded me of our education system here. That is, a certain level of humane care is provided to everyone, and for those who want more luxurious care, well, in free-market systems, suppliers will look for ways to capitalize on that demand.
Here in the US, we do have, in fact, a public-private system. My wife and I are on Tricare Prime. My primary care manager works in an Army clinic on Carlisle Barracks. I had my appendix removed in 2011 in a hospital on Fort Belvoir, Virginia. I pay an annual premium for myself and my wife that would stun anyone who pays even the subsidized rates in the PPACA exchanges. Last year, I had three minor medical procedures for which I paid a handful of $12 co-payments. These were done at private clinics as the local Army clinic does not have the facilities to perform the procedures. Tricare paid the clinics a negotiated rate for the procedures.
There are Facebook memes racing around, noting that the national cost of "Medicare for all" is actually much less than what we are paying nationally under our current approach. That, of course, assumes that everyone—poor and wealthy—will jump on that new system and be happy with it. I am less certain that will be so. It also points to a large economic disruption caused by, literally, trillions of dollars in reduced spending. There will be many business failures in a quick move like that, and that means many, many lost jobs.
All this leads to a question of how we can improve our system—make it more like France's, more like our education system, more like what I experience as a veteran—without creating economic havoc. I think there are a few things that we can do that turn our system carefully and reliably toward better health care. Each of these work from where we are today toward more care. They also give us an opportunity to evaluate which of these approaches work best and provide the best value for patients and for the nation. As each builds on existing systems, we can begin these modest changes just as soon as the appropriate legislation is passed.
- Patient Protection and Affordable Care Act Exchanges: Republicans and Democrats have noted that insurers are dropping out of some markets that they see as unprofitable, leaving customers with one or even no choices in some areas. We can fix this by providing a public-option carrier as discussed during the PPACA debate in 2009-10. The Center for Medicare and Medicaid Services (CMS) should be directed by Congress to develop a program to fill the gaps in areas with one or no choices and, if the program proves successful, to expand that into all markets. The CMS should develop plans that are equal in price and value to the average plans in the region and should tie their cost to the national rate of inflation. This may work to hold down costs to consumers by influencing the price increases of private insurance providers. CMS exchange plans will be eligible for the same cost subsidies as the private plans.
- Medicare: As others have suggested, we can begin lowering the qualifying age for joining Medicare. We can do this slowly and deliberately, lowering the age one year, each year, for three years and then pausing to evaluate the results. Lowering the age to 62 this way will bring millions more people onto the Medicare system without the very disruptive approach of suddenly opening up Medicare “for all.” This also allows us to test the feasibility of increasing revenue for this program on a much smaller scale than would be required if we opened Medicare to everyone.
- Medicaid: The Patient Protection and Affordable Care Act provided millions of Americans access to health care by raising the Medicaid threshold to 138-percent of poverty. We can continue this trend, slowly raising the threshold by a few percentage points each year until we reach 150 percent. As the benefit opens to more and more people, the pressure on states resisting the Medicaid expansion will increase, leading some to relent and offer care to millions more Americans. This initiative helps the people in the most need, including especially those in rural communities. It also helps ensure that rural hospitals and elderly care facilities get the support they need to remain open and able to serve their local communities. Distant hospitals mean slower access to life-saving care. Distant elderly care means family separations that create emotional harm for people in need.
- Department of Veterans Affairs: First, it should be clear to everyone that the VA’s health-care system needs vastly more resources after the wars in Afghanistan and Iraq created hundreds of thousands more patients with serious physical and mental conditions. That problem must be fixed immediately. However, we should not stop with just meeting that demand. The objective here should be to expand the VA system to support all veterans and then determine if providing services for active duty, reserve, and National Guard members is better and cheaper than under Tricare. When all veterans and service members are receiving high-quality care, we should then turn to considering whether to extend VA privileges to first responders. Volunteer fire departments are having a very tough time finding adequate numbers of qualified volunteers to protect your homes and businesses from harm. Being able to offer volunteers VA health care at the prices I pay for Tricare Prime could be a major draw for qualified volunteers.
All four of these ideas work to reduce the number of uninsured, un-serviced people in the United States. As the four approaches take on more patients, we can evaluate which are working and which are falling short. We can halt expansion on any or all and accelerate expansion on the best choice or choices. Most important, we can do so without severely disrupting a major economic sector and destabilizing our national economy. If the VA system proves the most effective—defined here as providing the best outcomes for the least money—then we know we probably want a larger national health-care system to accompany our private system. If the Medicare patients fare the best, then we know that we want Medicare for all. If Medicaid works best, then we know a system of support for the poorest, with progressive subsidies is essential. If the public option in exchanges proves popular and saves money for customers, then perhaps taking the profit motive out of health insurance is necessary. Of course, we are likely to find that we want a mix of approaches, just as we have now—but a mix that actually covers everyone well, for least possible cost. Everyone should know that our nation pays far more than other modern nations for health care, and we get poorer results. That wasteful approach must change.
It should be noted that these programs will reduce and might even eliminate the need for employers to provide health insurance for their employees. (It is possible also that this might have the effect of ending employer bias toward older employees as they transition from employer-purchased plans to Medicare.) The savings from purchasing less insurance must be replaced in part by a tax on employers that goes toward Medicare (and in some limited cases, Medicaid) for their employees. This can be a net savings for employers currently required to provide health-care insurance and can reduce the burden on other taxpayers. Included here is the expectation that our government will exercise the authority to negotiate costs with providers. This is an essential part of bringing down costs for everyone and is a reason so many advanced nations pay so much less than we do for better results than we get.
We started this nation on the idea that everyone had the right to life, liberty, and the pursuit of happiness. Today, we have people struggling just to stay alive. That condition enslaves them. It makes happiness a luxury out of their reach. This is a travesty. We are a great nation and a wealthy nation. We can ensure everyone has an equal chance to access the health care they need so that they can free themselves and enjoy a bit of happiness. We can do this. We must do this.
Two other things require mention. First, the hapless war on drugs has racked up enormous health costs for the nation. We need another approach, starting with prioritizing care for addicts over arrests. Second, Lyme disease is a public health menace, especially in the North East and nowhere more than in Pennsylvania. This needs a national focus. The Center for Disease Control and the National Institute of Health must find ways to better diagnose and treat Lyme disease.