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Healthcare reform in the United States

From Wikipedia, the free encyclopedia

Healthcare reform in the United States has a long history. Reforms have often been proposed but have rarely been accomplished. In 2010, landmark reform was passed through two federal statutes enacted in 2010: the Patient Protection and Affordable Care Act (PPACA), signed March 23, 2010,[1][2] and the Health Care and Education Reconciliation Act of 2010 (H.R. 4872), which amended the PPACA and became law on March 30, 2010.[3][4]

Future reforms of the American health care system continue to be proposed, with notable proposals including a single-payer system and a reduction in fee-for-service medical care.[5] The PPACA includes a new agency, the Center for Medicare and Medicaid Innovation (CMS Innovation Center), which is intended to research reform ideas through pilot projects.

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  • ✪ Transforming Health Care: Understanding the Affordable Care Act and What Might Come Next
  • ✪ The Healthcare System of the United States
  • ✪ History of Health Care in America - US 101
  • ✪ The Economics of Healthcare: Crash Course Econ #29
  • ✪ Behind Health Care Reform: An Insider's View: Stan Hupfeld at TEDxOU


[SIDE CONVERSATION] There's a line. Let me wait so a few more people can [INAUDIBLE]. [SIDE CONVERSATION] Good afternoon [INAUDIBLE]. We're going to get started, even though we have people who are still coming in. [INAUDIBLE] do have to stop on. The last question will be at 11:50. [INAUDIBLE] scheduling needs. So I wanted to introduce myself for those who don't know me. I'm [INAUDIBLE]. I'm the associate dean for communications and external relations at Harvard Medical School. And I am delighted to welcome all of you to today's Talk at 12. Though in addition to those in the audience, we are also welcoming individuals watching from around the through live streaming. Our last Talk at 12 on antibiotic resistance was viewed by more than 20,000 people around the world in 34 countries, as varied as Colombia, Costa Rico, Morocco, Canada, and Germany. And our last Talk at 12 was also viewed by 93,000 people on Facebook. So welcome to all of you. We predict this talk, transforming health care, understanding the Affordable Care Act, and what might come next will generate similar interest, given the public discourse and the many contrary views of how it should evolve. The Affordable Care Act, the ACA, was signed into law by President Barack Obama, as you may know, in 2010. The intention of the ACA was to provide millions of uninsured, low, and middle income Americans with some level of affordable health care insurance. It was designed to extend care to the most vulnerable, the young, the elderly, and those with preexisting conditions. The ACA continues to be a highly debated issue. There are those who believe health care should be accessible to all, but many don't agree on this basic fact. There are those who agree, but disagree on the methods on how to best achieve this goal. Some feel the most recent bill defeated in March did not go far enough to lower insurance costs. Others favored a more open market for insurers. A new bill is slated to be presented soon, perhaps even this week. As consumers, we're trying to make sense of all of this. And that's why we're delighted to have two of Harvard Medical School's health care policy experts talk us through the complexities. They'll try to anticipate what is in store for us. After the discussion, I hope you'll ask questions. We really want this to be more of a conversation and an exchange. And for those of you who are watching through Twitter, please send us your questions through our Twitter feed. Now today's two distinguished guests, Michael Chernew is a Leonard D. Schaeffer professor of health care policy and the director of the health care markets and regulation lab in the Department of Health Care Policy at HMS. Dr. Chernew's research focuses, most notably, on the causes and consequences of growth and health expenditures, payment reform, and value based insurance design. Dr. Chernew is a member of the Congressional Budget Office panel of health care advisors and of the Institute of Medicine Committee of National Statistics. He is the former vice chair of the Medicare Payment Advisory Committee. And in April 2015, Massachusetts governor Charlie Baker appointed Dr. Chernew to the Massachusetts Health Connector Board of Directors. And he was elected to the Institute of Medicine of the National Academy of Sciences. Joseph P. Newhouse is the John D. MacArthur professor of Health Care Policy and Management at Harvard University and director of the Interfaculty Initiative in Health Care Policy. He is a faculty member of Harvard Medical School, the Harvard Kennedy School, the Harvard TH Chan School of Public Health, and the Harvard faculty of Arts and Sciences. He is also a faculty research associate of the National Bureau of Economic Research. In 1981, he became the founding editor of the Journal of Health Economics, which he edited for 30 years. He is a member of the National Academy of Medicine and has served on the Board of Health Care Advisors, the Committee on National Statistics, the Science Technology and Economic Policy Board of the National Research Council, and was regent of the National Library of Medicine. He has won the Victor R. Fuchs Lifetime Achievement Award from the American Society of Health Economists, as well as numerous other awards and prizes for his research. We're delighted to have such esteemed members of our faculty talk to us today. Thank you both. [APPLAUSE] I thought I would start by telling you how I think about the Affordable Care Act or the ACA. It's inevitable to talk in acronyms when you're dealing with health policy. So I'll say ACA. I think the first thing to say is the ACA has 10 titles and only two of them are really relevant to what you're reading about in the newspapers almost every day. So, for example, there is a title approving pathways for biosimilars or biologics. There's a title on health workforce provisions. Those haven't really attracted much attention. And I think if there were a modification of the ACA to come out of the Congress-- which I'm skeptical about-- I think those titles would remain in place. So the titles that are really at issue are those around the Medicaid expansion and around the health insurance exchanges. It was helpful to me in thinking about those two titles to divide the population into four different groups of people. And I'll talk about them in turn, because the ACA really affects, mainly, two of the four groups. So the first group is probably the bucket that most of you fall into. It's the bucket Mike and I fall into, which is those with middle and large size group insurance. And for talking purposes, let's define that as people that work for employers of more than 50 who provide health insurance. So probably most of you, like the two of us, get our insurance through Harvard. For the most part, the ACA left that group alone. The one thing it did of note was it imposed a tax on employer plans with high premiums called Cadillac tax. The tax was unpopular, even at the time. So it was put off to go into effect until 2018. That was later deferred to 2020. I have my doubts that it will ever go into effect. But you probably haven't noticed much of a change in your benefits here because of the ACA. And that's true, actually, at most large employers. A little bit of, perhaps, anticipatory behavior for the Cadillac tax, but not a lot. So the second group are Medicare beneficiaries. This group, also, was relatively unaffected, compared to the other two groups I'll describe in a minute. There was in the drug benefit part D of Medicare, or is, something called a donut hole gap of no coverage. The amount where that starts and stops varies from year to year. It goes up with inflation. And it applied to generic drugs and brand drugs. There was no coverage for this gap in coverage. And the ACA is closing that gap over a 10 year period. So it'll be fully closed by 2020. Other than that, the ACA, again, mostly left Medicare alone. But it did cut reimbursement to hospitals and physicians. So for the physicians in the room, that was-- I'm sorry, not physicians, just hospitals and other institutional providers. MACRA, which the physicians in the room are probably familiar with, came along subsequently and drastically cut the rate of increase in physician services from fees from Medicare. But that's separate from the ACA. The other thing the ACA did on the Medicare front that's of note, is it established the Center for Medicare and Medicaid Innovation at CMS, which has been busily conducting various demonstrations. And Medicare, actually, started-- such as accountable care organizations-- Medicare, as a result, started to look somewhat different than it did a decade ago. That's all been something that's evolved from the ACA, nothing that was specific in the ACA, except for establishing the Center. So now, to the two groups that were definitely affected. The first group is those who are eligible for Medicaid and those who are uninsured. And the ACA expanded coverage, Medicaid coverage, to all citizens. In its original intent, it was to be to people below 138% of the federal poverty line. And it had a rather coercive provision that if a state didn't expand, and we're talking mainly about childless adults who didn't have coverage prior to the ACA through Medicaid. They weren't eligible for the remnant of our law from the English poor laws of the 19th century that said only, quote, deserving adults should be eligible for state aid. And if you were childless and not disabled, you were not in that category. But the ACA expanded coverage to that category. And, moreover, it said that if the state didn't expand, it would lose all its Medicaid funds. And the Supreme Court, in a case that did find the ACA mandate to have insurance constitutional, also declared that that provision was unconstitutional, ran, quote Justice Roberts, counter to the nation's tradition of federalism. And, therefore, states had the option to expand or not to expand. There's a lot of money on the table, federal money on the table, for the states, the initial three years for the expansion population. And we're going to be funded at 100%, tapering down to 90% in steady state. As of today, 31 states have expanded, and the District of Columbia. 19 have not. So the number of people who are insured through the ACA was not what was originally forecast. That's largely because of the not-- all states not expanding, including Texas and Florida, two of the four largest states. But that was the Medicaid expansion. There have been various provisions by the Obama administration to try to get states to expand, including so-called private option insurance. I won't go into that, unless there questions. Well, that's Medicaid and the uninsured. And, finally, there was the exchanges, which was the individual market and the small group market, meaning people that worked for employers under 50. This program, as you know, has had its problems. But there was-- in any individual insurance market, there's an incentive for, if everybody pays the same premium, for sick people to buy and healthy people not to buy, which economists call adverse selection. This happened in the ACA. The instruments that the ACA had in place to get at this were a mandate, meaning if you didn't buy you paid a penalty, and, importantly, subsidies that were a function of your income. The ACA also divided the country into states, and then marketplaces within states. There are several hundred such local marketplaces. Some of them have not gone well. Some of them have gone reasonably well. The Connector in Massachusetts, that Mike sits on, operates the Massachusetts exchange. I'll refer questions on the Massachusetts exchange to Mike. It's great. [LAUGHTER] And the issue is insurers, a lot of insurers, lost money initially. Some of that was because of actions the Congress took. One of the major issues, at the moment, is whether so-called cost sharing subsidies, which are subsidies that lower the cost sharing at the time of use for people under 250% of poverty, whether those will continue. The president has threatened that they won't. The estimate out there is that if they were removed, premiums on average would go up 19%. But the cost sharing would go up considerably for low income population. And undoubtedly, some of them would pull out. And undoubtedly, they would be the better risks. So this would exacerbate this [INAUDIBLE] whether this would-- what this would do, however, is pretty speculative. So let me stop with that. So to summarize, there's four groups of people. The people that worked for employers with more than 50 employees, ACA has largely unaffect-- left them unaffected. The Medicare beneficiaries closed the donut hole in Part D. Medicaid and the uninsured expanded Medicaid to childless adults at the state's option. And the individual market and small group market, left to buy through either the exchange or a small group market, still exists. But it doesn't function very well. Either some insurance among small employers has been declining and, of course, those people have the option of going to the exchange to buy insurance if they choose. So let stop and turn it over to Mike. Great. Well, thanks Joe. And I'm thrilled to be here. Just coming to listen to Joe's summary of the ACA is mostly what gets me here. But in any case, if you came hoping to know what health care is going to look like in 2020, maybe Joe knows. But, honestly, I don't. And I don't know if anybody does. So I want to talk about broad issues that the country faces regarding health care and how that might play out. So let me start with a very basic point. There's a certain amount of money that the country spends on health care. That money gets financed by the population, writ large. There's no magic tooth fairy that puts $10 thousand under your pillow if you have a heart attack. There's no money tree somewhere or rich Uncle Sam. One way or another, all the money comes from the population, goes through a bunch of other hands, insurers, and others, but ends up-- not all of it, necessarily, but the vast bulk of that-- ends up with a delivery system. And so, hopefully, no one tweeted to the four-year-olds watching us online that there's no tooth fairy, but, nevertheless, one way or another, we have to figure out what we're going to do. And it turns out that if that amount of money that we spend on health care services grows at the rate which it has historically grown, there's no amount of financing discussion, back and forth taxes pooling, that's going to solve that basic problem. We're getting to a point where there's just a fundamental fiscal problem that stems from the overall amount of money, and the rate of growth in the amount of money, that we spend on health care. And so when we think about the Affordable Care Act or whatever set of letters, the American Health Care Act or whatever new letters they put in place, it's all about how to manage that total pool of money. And then how it's going to be paid for. And in thinking about two different strategies, you have to think about the distributional fairness, who's paying and what the provisions of that bill do to control that total amount of spending. It's often said that the Affordable Care Act didn't do much to control health care spending, overall. That's that total pot of money. And that's probably, actually, not really true. Joe mentioned a number of ways they had, in Medicare, a number of provisions, which I think will not only help slow the rate of growth of Medicare health care spending, but, frankly, have spillover effects that might slow the growth outside of Medicare in a whole variety of ways. There's a series of other rules. The Cadillac tax, which Joe mentioned no one likes and has got postponed, but it was, never the less, in the law. There were other provisions in the exchanges of trying to promote insurer competition. So there was a lot of provisions in the Affordable Care Act that were, at least, intended to control health care spending. I'm not sure we've really cracked that nut as to how to do that. But, nevertheless, the Affordable Care Act had a bunch of things. And any replacement will undoubtedly have a bunch of other strategies. And I'm going to talk about those right now. So start with the basic premise that there's a big bag of money that we have that's going to health care in this country. And we have to finance that amount of money, one way or another. I want to talk about three broad ways that we might do that, where the Affordable Care Act sort of fit in that spectrum and where the new administration and Congress might go. So the first way to finance that is through taxation. So death and taxes, necessary evils. Taxes have a dampening effect on the economy. I don't know if anyone loved taxes. But it is a mechanism to finance a whole variety of things that the government does. And, it turns out, that it is mandatory. And it tends to be progressive. Richer people pay more, by and large, than poor people. And you could use that money to finance health care, plus a whole bunch of other things. And, of course, tax policy is incredibly controversial and will also be-- there's probably across the river, somewhere, a seminar at noon on what they're going to do for tax policy. But in any case, it remains a fundamental controversy about how much we should rely on tax financing to support health care. The second way of thinking about supporting health care financing is through premiums. And this gets at why health care is a somewhat unique product. It's not like broccoli. Unlike most products when you purchase the products, the cost of health insurance depends on who buys the health insurance. That is different than most products that you buy, at least qualitatively. It's much more important. So essentially, the health insurance, by its nature, pools people together. And I want to draw a distinction between two types of pooling. There's pooling between my brother and I. And you don't know him. We're actually quite different. But, because you don't know him, I'll make up some things. He may be watching. In any case, imagine we're basically exactly the same. It's the beginning of the year. And we buy insurance. Maybe we have the exact same risk. One of us may be lucky. One of us may be unlucky. It turns out, it's always my brother. But that's a separate story. But at the end of the year, it turns out the lucky one, through their premiums, has effectively subsidized the unlucky one. But at the beginning of the year, it was totally fair, because you didn't know at the beginning of the year who was going to be lucky and who wasn't. So there a cross-subsidisation. But when you bought the insurance, it was really not a question of fairness. Everyone was, basically, pitching in to pool their risks. Then there's another type of coverage, which would say pooling, which might be, say, between me and my dad-- which isn't exactly right since he's on Medicare, but anyway-- where people have fundamentally different risks. You know some people are high risk with chronic disease. And some people are low risk without chronic conditions. And if you force them into the same insurance pool, the people who are healthy are effectively subsidizing the people that are sick. And it's not necessarily simply because some of them are lucky or unlucky. You know going in that some subset of people are paying more than, essentially, their fair share would be if they were just paying for their own risk. But they're paying part for their own risk. And they're also paying for the risk of people that are higher risk than them. And, of course, the people that are a higher risk are benefiting from that cross-subsidy. That sort of pooling is accomplishing both the risk per risk mitigation part of insurance, but it's also accomplishing this type of cross-subsidisation that goes on, in some ways functioning like a tax on the lower risk people. And, as Joe mentioned, there is a tendency for those markets to try and unravel, because you don't want to be an insurance pool with my dad. How they separate out is challenging. The Affordable Care Act, through a whole number of mechanisms, some of which Joe mentioned-- the mandate, the subsidies, a whole bunch of things-- tried to push those groups together. And do it in a way that's essentially trying to bring the healthy people in. But bring them in at a premium that's slightly higher than the actual fair premium for them, because that extra amount of money is being used to finance the people that are somewhat sicker. If they came in and just paid the premium that was the appropriate premium for them, it wouldn't help solve the problem that the sicker people have much higher premiums that they can't really afford. So that's one financing mechanism, which is inherently unstable because of the tendency of the healthy people to try and get away from the sick people, at least in terms of their insurance pool. We love them, but, anyway, you don't want to be in their insurance pool. The other way to do some type of cross subsidy, is to have people pay more for their care, at the point of service. So when you go to the hospital or the doctor, you pay something out of pocket. You're now charging not necessarily the high risk people, but the people who end up sick during the course of the year. Even the healthy people end up sick. There's always that person who was super healthy and got hit by a bus or had a bad disease. Those people may have bought an insurance policy that was very cheap. And they thought it was perfect, because they never need health care. Some of those people that never need health care turns out will need health care. And you can finance some of that health care spending by charging people when they get sick. So that is problematic, in the sense that it imposes risk. Remember insurance-- should be clear from the name-- is designed to mitigate that risk, so you don't face the very high expenses when you get sick. That's, in many ways, the economic purpose of insurance, which is diminished when you have to pay all out-of-pocket. But the advantage of charging people out-of-pocket is it helps them manage their health care spending. It's a little daunting to make that point, sitting next to Joe, because the seminal work on this was done by Joe in the RAND Health Insurance Experiment. But the point remains. If you tax people, or if you just make them buy an insurance policy and pay through their premiums, you're not doing very much to control health care spending growth. If you charge them more at the point of service, for better or worse, you actually will reduce the amount of health care spending. And the price you pay societally for that is your imposing risk on people. And you're typically charging the sick people more than the healthy people, because they're the ones that go to the doctors and the hospitals more. And there's a whole series of other issues related to income distribution consequences of forcing people to pay out-of-pocket when they get sick. The fundamental debate that we're having, now, is between the mechanisms that the Affordable Care Act put in place, some combination of taxing and forcing people into a common pool to handle that financing problem, with where I think the current administration and Congress want to go-- although, frankly, I'm not sure where they want to go. So this is my impression, not necessarily true. But in a way which is charge people more at the point of service by encouraging them to enroll in plans that are less generous than the plans that the Affordable Care Act set in place. So there's a bunch of things-- the essential benefits, the actual value rules-- which determine how generous plans have to be that are in the Affordable Care Act that the current drafts of things have tried to release, relax, combined with reduce taxation by reducing the amount of premium support going into the system. And they are and has been, as Gina pointed out, they were not quite successful in getting a version of this to the floor a month or so ago. And so, now, they're taking a crack at it, again. And the issues, basically, are how much money are they going to put in the system, taxpayer funded money, are they going to put in the system, and how are they going to direct that money to offset the cost, largely, of the people that are using a lot of health care, particularly the people that are high risk people. So there's issues of high risk pools and reinsurance schemes and a bunch of other things that are really too technical to talk about, at least in my intro. But, by and large, it all has the flavor of charging people who are sicker, ex-ante, more than they would have had to pay in the Affordable Care Act and charging the people who get sick during the course of the year more than they would have paid in most Affordable Care Act policies. And you may argue the social equity of that. I don't want to argue the social equity of that. But economists are much more equipped to talk about efficiency than equity. But that seems to be the sort of philosophical direction that the current Congress and administration seems to be going in. And the point they make-- which is, in fact, true-- is we can't manage the rate of health care spending growth that we've experienced in the past going forward. And we need this type of fiscal discipline, if you will, in order to ultimately slow the rate of health spending growth. Whereas, admittedly, that will cause adverse consequences for a range of people, particularly people that are ex-ante sick, people that are depending on the subsidy scheme relatively lower income in the grand scheme of things, or who get sick over the course of the year. And again, the details of that matter. And we haven't yet seen the bill that threads that needle between what is politically acceptable and what they think is-- meets their other fiscal goals. So that's what I think the tension is. That's where I think the debate is. It's, in part, a debate about efficiency and how to control that overall amount of spending that's going into the health care system. And it's part a debate about the distributional consequences. Too often, I think, it's poised as a debate about premiums. But, understand, I can make premiums really low, if I just gave everybody a $20,000 deductible. Premiums are just one way by which people pay for their care. And so you take the total cost into account. You think who's going to pay for it. And how is that going to affect the aggregate amount of spending? So that's where, I think, the tension is. And I look forward to questions. Gina might ask some. Thank you, both. Again, if you're watching through Facebook or through our live streaming, send us your questions at @talksat12. T-A-L-K-S-A-T-12. Thank you. Are there questions? We have microphones. [INAUDIBLE] So we are going into the social [INAUDIBLE], why does no incentive, like for the prevention, for example. At the end of the year, if I am having good health, a portion of it should be returned to me, for the insurance costs, just like in taxes. At the end of the year, we do the taxes. And you get some of the more big based on the insurability They would also use the cost of the health insurance, also, would be in it. Could you repeat the question? Yes, I'll repeat the question. So the question is why isn't there more reward for preventive behavior or possibly amounts refunded at the end of the year. I'd make a couple of points. First, the ACA did make all preventive services free. So while there's a lot of cost sharing, high deductible plans, and so forth, in all plans, preventive services are to be free. There's a whole debate about what constitutes preventive services. But it's defined by the US Preventive Services Task Force. That's one point. Second point-- as Mike referred to high cost sharing, large deductibles, co-insurance and so forth, if one is successfully preventing illness, which, of course, could be by lifestyle, such as exercise or diet or tobacco non-use and so forth, one will be spending less on cost sharing, presumptively. It will be going less to the hospital and so forth. So I would say there are rewards and incentives in the ACA for preventive behavior. We can argue about, maybe, they should have been greater. But they are there. And I've said two things first is I'm a huge supporter of prevention. I have, actually, two wristbands on to make sure I get all of my steps, because I'm also a little OCD. But that said, the evidence of prevention, at least all these programs to increase prevention, save money is quite dubious, as a general rule. Picking up on what Joe said, the prevention that is free in the Affordable Care Act is primary prevention, getting largely cancer screenings things like that, as opposed to secondary prevention managing your diabetes, managing your heart disease. And there's a big controversy around that. And I've been quite involved in trying to support that type of prevention. But I think one of the fundamental issues that you raise has to do with the equity between people that are healthy, versus not, at a point in time, and how much the people that have maintained their health should subsidize the people that are less healthy, which again, may be because of their behavior, may be because of a bunch of whole other reasons. And so there's a bunch of discrimination issues that arise in thinking about how much you should charge a healthy person versus a sick person, because only a portion of the health difference is related to prevention or behavior. There's a lot of the health difference that's related to a whole bunch of other things. And that becomes a broader philosophical equity issue, which, gratefully, you asked us not to address. Susan. Thank you. My question is in respect to how healthy are preventative medicine [INAUDIBLE] preventive [INAUDIBLE]. Most of all, there is a lot of genetics material that can make things appear out of space. I am an advocate for health equality. I'm wondering why these [INAUDIBLE] administration is what's the [INAUDIBLE] in place to help the weak, the poor, and the sick try to get a life that they deserve, in which ACA has tried to give to them by making health care affordable and all. I think the quick answer is there are, certainly, some protections and subsidies in the current law. They are not as great as in the Affordable Care Act and, now, reflects a series of priorities that might not match the priorities that you eloquently vocalized. So I don't have a great answer for why they want to do what they want to do. I think it largely has to do with meeting the fiscal challenges that they see in the future. But the debate now is essentially how much of those types of protections and what form they should be in the new rule and what form those protections should take. But I think it's probably safe to say that, for the most part, the protections in what is being discussed moving forward would be weaker than the protections that were under the Affordable Care Act. We're not advocating anything, one way or another, incidentally. I'm just saying that's my take of the situation. Dr. Chernew, Dr. Newhouse, I'm curious. In the new plan that we ant-- what do you anticipate we're going to see, any of the provisions of the Trump, Ryan plan that will be reprised? Well, first of all, I don't think it's 100% we're going to see a new plan. I gave a talk about the future of health care. And my first slide, the title of the slide, said let's start with the honest answer to this question. So I had a picture of a crystal ball. So I-- I just don't know. As Mike said, if they move to the right, they lose votes on the left. I, personally, thought the political history would be they would get a vote out of the House. I was a little surprised it would go to the Senate. The Senate would probably pass some kind of very different bill through reconciliation, so-called. And then the whole thing would probably come apart in conference, because the Senate and the House wouldn't be able to agree on a bill that could pass both houses. But we haven't even gotten to that stage, yet. So I don't want to try to predict what this modified bill will look like. Yeah, I think one of the challenges is there's a number of things that may happen that will affect the way the Affordable Care Act functions. So you should not assume that simply because the Affordable Care Act remains the law of the land that the Affordable Care Act will function the way the Affordable Care Act has functioned-- the biggest of which, Joe mentioned, is the cost sharing subsidies, which are currently being debated and you'll see debated a lot. If they decide-- if they, the administration and Congress, decide not to fund the cost sharing subsidies-- in fact, even if they decide to fund them, but they just wait quite long enough and do a bunch of other things they may cause the exchange, which is one of Joe's four segments, to collapse in a whole variety of ways without having to get anything through the House or the Senate. And the fundamental question, there, will be who is to blame. And if that does happen, and they come to the floor now with a bill having the Affordable Care Act effectively not functioning, what will people on the political left do? So there's one view that they will say, you broke it. You own it. Let's take it to 2018 and let it play out. I'm not saying they should or would do that. There's another view, which is there's so many people that are suffering in a variety of ways. We will accept a much weaker bill going forward, just to get something as opposed to naught. And, again, I don't have a good answer as to how that will play out. But don't believe that simply because they can't get a bill through Congress the Affordable Care Act will function the way that it has. And just to give you a little more detail, the House Republicans, when they were-- when President Obama was in office, brought a lawsuit, saying that the administration-- it was unconstitutional for the administration to pay these subsidies, because the Congress had not appropriated the money. And a federal district court judge in Washington actually found for the House in that lawsuit. And the Obama administration, this was near the end of the Obama administration, appealed. And then we had the election. President Trump was inaugurated. And all of a sudden there was this lawsuit from the House Republicans on appeal to stop the cost sharing subsidies. The Trump administration could, of course, decided to drop the appeal, in which case, the cost sharing subsidies would-- the federal district court judge decision that they were unconstitutional would have held. And they would have disappeared. So the House, which now, since the Republicans were now the governing party, was having second thoughts about whether they really wanted to do this. Ask the court, the appeals court, for a stay, which the appeals court granted. So the original decision is stayed. The stay expires May 22nd. But, as Mike said, the insurers have to decide what they're going to do before then about submitting bids for 2018. At least, in most states they're going to have to decide. Some states have given an extension to June 1, but that's still a very narrow window. So if the exchanges are going to function reasonably well in 2018, it's going to be important for there to be some clarity about what's going to happen with these cost sharing subsidies in the next few weeks. We have a question from Twitter. This question is from Michael Chernew. Medicare faces long term fiscal challenges. How do you see reform of Medicare taking place? Will benefits be cut or will premiums or cost be sharing-- I'm sorry. Will premiums or cost sharing be increased? Medicare does face fiscal challenges going forward, largely, because of the demographics, quite frankly. It turns out when you have more people on Medicare, you have to have the people paying taxes pay more. That's-- you don't need a lot of math to figure that out. And that becomes problematic in a variety of ways, at least politically, quite problematic. As Joe mentioned in his excellent summary, there was a lot that was put in place in the Medicare program to try and control the rate of spending growth per capita through reducing fees to facilities, through innovation and payment, through the Center for Medicare Innovation, the Innovation Center. I believe that the hope is that those things will pay off in a way that will alleviate the pressure on Medicare and any shortfalls be made up through taxes. I do not see further fee cuts in the future. Physicians are going to get a fee in inflation adjusted terms anyway, given the MACRA law that Joe mentioned. And the facilities are getting fee increases that are below the cost of their inputs. So I don't see fees going up more slowly. And I don't see dramatic changes to make benefits less generous, just given the way that the population is on Medicare votes. So my sense is that if they can't-- if those things don't work sufficiently, there will be some attention to either taxes, maybe eligibility rules in a variety of ways, maybe means testing premiums in Medicare, things of that nature. But I think the hope in the near term is that the things put in place as part of the Affordable Care Act and other laws like MACRA will be sufficient to control the rate of spending growth. Although admittedly, the current forecast suggests that's not the case when you get out to 10 years from now. But we will have to see how that plays out. There is a related feature of the Affordable Care Act, which is a surcharge of 9/10 of a percent on income for high income individuals to the payroll tax to finance Medicare. If that is repealed, which is part of the Republican bill that didn't pass, that would advance the time at which the Part A, that's the hospital part of Medicare, goes to a zero balance, which the press says means go broke. But that's not quite right. That goes back from 2028 to 2025. So there is an impact on Medicare, but of a larger financing problem. Another question. It Seems to me that part of the problem is the evolution of the term insurance, which really is for something that's unlikely, like a tornado. If you look at people who are under Medicare age, the majority of patients who will have the majority of costs, we know them already. It's not a surprise, because they have chronic conditions. The majority of costs, now, go to people who already have a diagnosis. It seems that we need to work much harder at identifying those groups, figuring out how to care for those, and then the truly low risk people leftover, as you discuss, become a simpler issue. And plus, that improves the incentives to get really good care for these chronic conditions that we already know are very expensive. So that, hopefully, was the theme of my intro, in some ways, that that is the crux of the problem, that there are people that have high expected expenditures to some extent, although not perfectly I might add, to some extent they can be predicted. And the question, then, is who pays for them. The answer is either they pay for themselves, which seems problematic in a bunch of ways, that we pay for them through taxes or by charging the healthier people higher premiums. That's the basic issue. We have not, yet, figured out a great way to control the amount of spending that those people make. And in fact, it has typically not been the case that giving them more care or better care lowers their overall spending, And that's just, unfortunately, the way that the innovations look. To the extent that delivery systems can do a better job of that, then the world would be a better place. But that has been hard to do. No, but I mean, for instance, for renal failure, which is clearly, now, a carve out. At least then we're dealing with the problem that we have, rather than diluting it with a totally separate problem, which is how much to get from the healthy. If we at least are focusing on the individual chronic conditions and what constitutes a high enough risk if they pull out. There are not a lot of things that there's bipartisan agreement on. But there is a fair amount of bipartisan agreement on a move to shift risk downward toward providers, or provider groups, really, which goes under the banner of value based purchasing, which is a little bit of a misnomer in my view. But in any event, it would shift risks somewhat away from insurers or purchasers, including Medicare, toward provider groups, as I said. And one of the reasons, or rationales, for that is that, then, the provider groups would have an incentive to coordinate care for the chronically ill and try to reduce their use of services in the future. We have a question, here, another one, here, and one at the top of the room. Yeah. So this might be a somewhat trivial question. So ACA tries to harmonize, or bring together, very different interests in society. And the American societies are heterogeneous in this, in their risk assessment or social responsibility and so forth. Now, to some extent different states have different overall, average view of these issues, like Massachusetts tends to vote in a different way than, for example, Texas. So why aren't these problems tested for the next 10 years at the state level, trying to find different models, whichever works. For Massachusetts, there's a 99% coverage in health insurance. So other states would try something else that would be more in concert with their own view. So the issue is simple. The first part is just money. Massachusetts gets money. And so how much money should the feds give to the states to do that? And the second one is concern in different parts of the political spectrum about the people that end up in states that have a solution, if you will, or approach to that problem that not everybody likes. So there's some sense in which the federal government is trying to impose certain types of standards across all of the states to manage that issue. Medicaid expansion would be an example of where that would be the case. Though one of the fault lines that runs throughout American history, starting with the Constitution, is the role of the states versus the role of federal government. And you can see that play out, certainly, as Mike said, in the Medicaid decision of the Supreme Court. But at bottom, there's an issue about, for example, should Massachusetts voters have the prerogative to say to residents of Texas that you should provide better health care for poor people in Texas. Or should that be left to people in Texas. Another way to say that is when we say the United States. Is the emphasis on the United? Or is it on the states? And this is just a tension in the American, political, governmental system. It has been there since the founding of the country. And it's still there. So go see Hamilton. [LAUGHTER] We have two more questions. One, and then we'll have to stop. One of my good friends, a former president of one of the partner's hospitals, said something that happened to be the same thing that one of the major fidelity economists mentioned to me, too, on the tennis court one day-- that there's not enough money to afford the Affordable Care Act and so that it was not going to succeed. It was inevitably bound not to work. And then a Republican friend of mine in the Midwest said something I didn't expect to hear from him, which is basically, that he thought that single payer was inevitable, which is kind of consistent with those other two comments. And I wondered what both of you think about the inevitability of single payer? Inevitable, I think, is too strong of a word. But I certainly could see a path should the Affordable Care Act collapse through law or neglect that we move to provide care for people at some basic level. Single payer means different things to different people in a whole variety of complicated ways. But through expansions of Medicaid, through people buying into Medicare, through a whole series of things, we could certainly move in that direction. The notion that there's not enough money for the Affordable Care Act, but there would be for a single payer, doesn't make a lot of sense to me. Again, a lot of that's a lot of complicated hand-waving when the basic point is there's a certain amount of health care spending. There's a certain number of people. The people have to pay for the health care spending. And so one way or another, the question is how much health care are they going to go. And a lot of that not enough money means, is code for, we're not willing to tax ourselves enough. We're not willing to put enough pressure on the suppliers of health care to be able to afford it. But there, also, is the escalation part, that the health care expenses, and you've alluded to this, continue to escalate very steadily. And if we can't solve that, there is-- it's true. If health care spending grows to 2% faster than GDP, it turns out there will, mathematically, be not enough money for health care. We'll be running around healthy and naked, whatever it happens to be. There will be no food. Right? I mean, yes, that's the way the math works out. And so if we don't solve the rate of growth in health care spending part-- it's great to be here to talk about the Affordable Care Act or the American's Health Care Act or whatever other act they want to put in place. But if you can't solve the health care spending growth problem, it's just a matter of time before you have this other problem. And the Affordable Care Act tried to do that. I would just add that single payer is not the only necessary tool for that question. I mean, you can have some kind of all payer rate regulation, which we've had in various states, at times. It hasn't worked very well, but that's a different issue. I'd like to-- Can we take one last question? One last question. Yeah, one last question. And I-- we could be here for another hour. We'll have 12 at noon another time. So I like the example you gave of the bag of money that we all have to split for everybody to have health care. And, from the discussion, it seems that everything that's been going on is people fighting over the same amount of money, and who gets a chunk of it, who gets insurance, who doesn't. I like the direction of the Affordable Care Act in that it's moving towards giving everybody health insurance. My question is what are the provisions. What are examples of provisions that were put in health care laws that would try and focus on spending some of that money on actually reducing the cost of health care, in terms of health care design, for example, new innovations that costs less. Are there any laws that make sure that some of that money goes in that direction to better make use of that money? Well, the thing that comes first to mind was the thing we've already discussed, the Center for Medicare and Medicaid innovation. That was part of the ACA. A lot of Republican voices didn't like that Center when they were out of power, I think, there's been some rethinking about that since they're in power. But one of the things to keep your eye on is what happens to the monies and the authorities of that Center. I think one of the challenges is your basic philosophy to do that there's a view in which the government is more prescriptive. And they take money and they pick things, like information technology or prevention or pick whatever you want, and try and funnel money toward-- telemedicine-- they try to funnel money towards those things. That's one strategy. I'm actually a little skeptical on a lot of that strategy. But that is one strategy. The Affordable Care Act-- and frankly, I think going forward, we'll see more of this-- is less about picking those winners and losers and more about putting the responsibility to develop those innovations on the delivery system by giving the delivery system a set of incentives to be sufficiently innovative underneath. It's turned out that has been a hard thing to have happen. Many people thought, they still think, there's 30% waste in the system. And if we change the incentives, 30% of health care spending will just melt away. And it turns out that the innovations have saved a little bit of money, that it's a lot harder to change provider behavior and come up those innovations. And when you try and find those innovations directly through IT, you don't nearly get the savings. It's proponents of those things said you would get. So I think the Innovation Center that Joe mentioned and, I think, the broad philosophy both of the ACA and of where the system is going outside of the ACA, and where the new administration and Congress would take it, are all about having the incentives go down to the delivery system to let them do what they want to do, as opposed to having the government, certainly the federal government, pick selected winners. And some of the things that might help is relaxing a certain types of regulations-- I won't go through all of them because of time-- to try and give those organizations a little more flexibility to do that. But we're at the beginning of that process. Dr. Newhouse, Dr. Chernew, thank you so much. [APPLAUSE] There's much to talk about. There's much to talk about in the months to come. We'd love to invite you back. [SIDE CONVERSATION]


History of national reform efforts

The following is a summary of reform achievements at the national level in the United States. For failed efforts, state-based efforts, native tribes services, and more details, see the history of health care reform in the United States article.

  • 1965 President Lyndon Johnson enacted legislation that introduced Medicare, covering both hospital (Part A) and supplemental medical (Part B) insurance for senior citizens. The legislation also introduced Medicaid, which permitted the Federal government to partially fund a program for the poor, with the program managed and co-financed by the individual states.[6][7]
  • 1985 The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) amended the Employee Retirement Income Security Act of 1974 (ERISA) to give some employees the ability to continue health insurance coverage after leaving employment.[8]
  • 1996 The Health Insurance Portability and Accountability Act (HIPAA) not only protects health insurance coverage for workers and their families when they change or lose their jobs, it also made health insurance companies cover pre-existing conditions. If such condition had been diagnosed before purchasing insurance, insurance companies are required to cover it after patient has one year of continuous coverage. If such condition was already covered on their current policy, new insurance policies due to changing jobs, etc... have to cover the condition immediately.[9]
  • 1997 The Balanced Budget Act of 1997 introduced two new major Federal healthcare insurance programs, Part C of Medicare and the State Children's Health Insurance Program, or SCHIP. Part C formalized longstanding "Managed Medicare" (HMO, etc.) demonstration projects and SCHIP was established to provide health insurance to children in families at or below 200 percent of the federal poverty line. Many other "entitlement" changes and additions were made to Parts A and B of fee for service (FFS) Medicare and to Medicaid within an omnibus law that also made changes to the Food Stamp and other Federal programs.[10]
  • 2000 The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) effectively reversed some of the cuts to the three named programs in the Balanced Budget Act of 1997 because of Congressional concern that providers would stop providing services.
  • 2003 The Medicare Prescription Drug, Improvement, and Modernization Act (also known as the Medicare Modernization Act or MMA) introduced supplementary optional coverage within Medicare for self-administered prescription drugs and as the name suggests also changed the other three existing Parts of Medicare law.
  • 2010 The Patient Protection and Affordable Care Act, called PPACA or ACA but also known as Obamacare, was enacted, including the following provisions:[3]
    • the phased introduction over multiple years of a comprehensive system of mandated health insurance reforms designed to eliminate "some of the worst practices of the insurance companies"—pre-existing condition screening and premium loadings, policy cancellations on technicalities when illness seems imminent, annual and lifetime coverage caps
    • created health insurance marketplaces with three standard insurance coverage levels to enable like-for-like comparisons by consumers, and a web-based health insurance exchange where consumers can compare prices and purchase plans.
    • mandates that insurers fully cover certain preventative services
    • created high-risk pools for uninsureds
    • tax credits for businesses to provide insurance to employees
    • created an insurance company rate review program
    • allowed dependents to remain on their plan until 26
    • It also sets a minimum medical loss ratio ratio of direct health care spending to premium income creates price competition
    • created Patient-Centered Outcomes Research Institute to study comparative effectiveness research funded by a fee on insurers per covered life
    • allowed for approval of generic biologic drugs and specifically allows for 12 years of exclusive use for newly developed biologic drugs
    • many changes to the 1997, 2000, and 2003 laws that had previously changed Medicare and further expanded eligibility for Medicaid (that expansion was later ruled by the Supreme Court to be at the discretion of the states)
    • explores some programs intended to increase incentives to provide quality and collaborative care, such as accountable care organizations. The Center for Medicare and Medicaid Innovation was created to fund pilot programs which may reduce costs;[11] the experiments cover nearly every idea healthcare experts advocate, except malpractice/tort reform.[12]
    • requires for reduced Medicare reimbursements for hospitals with excess readmissions and eventually ties physician Medicare reimbursements to quality of care metrics.
  • 2015 The Medicare Access and CHIP Reauthorization Act (MACRA) made significant changes to the process by which many Medicare Part B services are reimbursed and also extended SCHIP
  • 2017 Donald Trump is sworn in as President, signs Executive Order 13765 in anticipation of a repeal of the Patient Protection and Affordable Care Act, one of his campaign promises. The American Health Care Act is introduced and passed in the House of Representatives and introduced but not voted upon in the Senate. President Donald Trump signs Executive Order 13813 which allows insurance companies to sell low-cost short-term plans with lesser coverage, enables small business to collectively purchase association health plans, and expands health savings accounts.


Bar chart comparing healthcare costs as percentage of GDP across OECD countries
Bar chart comparing healthcare costs as percentage of GDP across OECD countries
Medicare and Medicaid Spending as % GDP (data from the CBO)
Medicare and Medicaid Spending as % GDP (data from the CBO)
Chart showing life expectancy at birth and health care spending per capita for OECD countries as of 2015.  The U.S. is an outlier, with much higher spending but below average life expectancy.[13]
Chart showing life expectancy at birth and health care spending per capita for OECD countries as of 2015. The U.S. is an outlier, with much higher spending but below average life expectancy.[13]
Health spending per capita, in US$ PPP-adjusted, compared amongst various first world nations.
Health spending per capita, in US$ PPP-adjusted, compared amongst various first world nations.

International comparisons of healthcare have found that the United States spends more per-capita than other similarly developed nations but falls below similar countries in various health metrics, suggesting inefficiency and waste. In addition, the United States has significant underinsurance and significant impending unfunded liabilities from its aging demographic and its social insurance programs Medicare and Medicaid (Medicaid provides free long-term care to the elderly poor). The fiscal and human impact of these issues have motivated reform proposals.

U.S. healthcare costs were approximately $3.2 trillion or nearly $10,000 per person on average in 2015. Major categories of expense include hospital care (32%), physician and clinical services (20%), and prescription drugs (10%).[14] U.S. costs in 2016 were substantially higher than other OECD countries, at 17.2% GDP versus 12.4% GDP for the next most expensive country (Switzerland).[15] For scale, a 5% GDP difference represents about $1 trillion or $3,000 per person. Some of the many reasons cited for the cost differential with other countries include: Higher administrative costs of a private system with multiple payment processes; higher costs for the same products and services; more expensive volume/mix of services with higher usage of more expensive specialists; aggressive treatment of very sick elderly versus palliative care; less use of government intervention in pricing; and higher income levels driving greater demand for healthcare.[16][17][18] Healthcare costs are a fundamental driver of health insurance costs, which leads to coverage affordability challenges for millions of families. There is ongoing debate whether the current law (ACA/Obamacare) and the Republican alternatives (AHCA and BCRA) do enough to address the cost challenge.[19]

According to 2009 World Bank statistics, the U.S. had the highest health care costs relative to the size of the economy (GDP) in the world, even though estimated 50 million citizens (approximately 16% of the September 2011 estimated population of 312 million) lacked insurance.[20] In March 2010, billionaire Warren Buffett commented that the high costs paid by U.S. companies for their employees' health care put them at a competitive disadvantage.[21]

Life expectancy compared to healthcare spending from 1970 to 2008, in the US and the next 19 most wealthy countries by total GDP.[22]
Life expectancy compared to healthcare spending from 1970 to 2008, in the US and the next 19 most wealthy countries by total GDP.[22]

Further, an estimated 77 million Baby Boomers are reaching retirement age, which combined with significant annual increases in healthcare costs per person will place enormous budgetary strain on U.S. state and federal governments, particularly through Medicare and Medicaid spending (Medicaid provides long-term care for the elderly poor).[23] Maintaining the long-term fiscal health of the U.S. federal government is significantly dependent on healthcare costs being controlled.[24]

Insurance cost and availability

In addition, the number of employers who offer health insurance has declined and costs for employer-paid health insurance are rising: from 2001 to 2007, premiums for family coverage increased 78%, while wages rose 19% and prices rose 17%, according to the Kaiser Family Foundation.[25] Even for those who are employed, the private insurance in the US varies greatly in its coverage; one study by the Commonwealth Fund published in Health Affairs estimated that 16 million U.S. adults were underinsured in 2003. The underinsured were significantly more likely than those with adequate insurance to forgo health care, report financial stress because of medical bills, and experience coverage gaps for such items as prescription drugs. The study found that underinsurance disproportionately affects those with lower incomes—73% of the underinsured in the study population had annual incomes below 200% of the federal poverty level.[26] However, a study published by the Kaiser Family Foundation in 2008 found that the typical large employer preferred provider organization (PPO) plan in 2007 was more generous than either Medicare or the Federal Employees Health Benefits Program Standard Option.[27] One indicator of the consequences of Americans' inconsistent health care coverage is a study in Health Affairs that concluded that half of personal bankruptcys involved medical bills,[28] although other sources dispute this.[29]

There are health losses from insufficient health insurance. A 2009 Harvard study published in the American Journal of Public Health found more than 44,800 excess deaths annually in the United States due to Americans lacking health insurance.[30][31] More broadly, estimates of the total number of people in the United States, whether insured or uninsured, who die because of lack of medical care were estimated in a 1997 analysis to be nearly 100,000 per year.[32] A study of the effects of the Massachusetts universal health care law (which took effect in 2006) found a 3% drop in mortality among people 20–64 years old—1 death per 830 people with insurance. Other studies, just as those examining the randomized distribution of Medicaid insurance to low-income people in Oregon in 2008, found no change in death rate.[33]

The cost of insurance has been a primary motivation in the reform of the US healthcare system, and many different explanations have been proposed in the reasons for high insurance costs and how to remedy them. One critique and motivation for healthcare reform has been the development of the medical–industrial complex. This relates to moral arguments for health care reform, framing healthcare as a social good, one that is fundamentally immoral to deny to people based on economic status.[34] The motivation behind healthcare reform in response to the medical-industrial complex also stems from issues of social inequity, promotion of medicine over preventative care.[35] The medical-industrial complex, defined as a network of health insurance companies, pharmaceutical companies, and the like, plays a role in the complexity of the US insurance market and a fine line between government and industry within it.[36] Likewise, critiques of insurance markets being conducted under a capitalistic, free-market model also include that medical solutions, as opposed to preventative healthcare measures, are promoted to maintain this medical-industrial complex.[36] Arguments for a market-based approach to health insurance include the Grossman model, which is based on an ideal competitive model, but others have critiqued this, arguing that fundamentally, this means that people in higher socioeconomic levels will receive a better quality of healthcare.[35]

Uninsured rate

With the implementation of the ACA, the level of uninsured rates severely decreased in the U.S. . This is due to the expansion of qualifications for access to medicaid, subsidizing insurance, prevention of insurance companies from underwriting, as well as enforcing the individual mandate which requires citizens to purchase health insurance or pay a fee. In a research study which was conducted comparing the effects of the ACA before and after it was fully implemented in 2014, it was discovered that racial and ethnic minorities benefited more than whites with many gaining insurance coverage which they lacked before allowing for many to seek treatment improving their overall health.[37] In June 2014, Gallup–Healthways Well–Being conducted a survey and found that the uninsured rate is decreasing with 13 percent of U.S. adults uninsured in 2014 compared to 17 percent in January 2014 and translates to roughly 10 million to 11 million individuals who gained coverage. The survey also looked at the major demographic groups and found each is making progress towards getting health insurance. However, Hispanics, who have the highest uninsured rate of any racial or ethnic group, are lagging in their progress. Under the new health care reform, Latinos were expected to be major beneficiaries of the new health care law. Gallup found that the biggest drop in the uninsured rate (3 percentage points) was among households making less than $36,000 a year.[38][39][40]

Waste and fraud

In December 2011 the outgoing Administrator of the Centers for Medicare & Medicaid Services, Donald Berwick, asserted that 20% to 30% of health care spending is waste. He listed five causes for the waste: (1) overtreatment of patients, (2) the failure to coordinate care, (3) the administrative complexity of the health care system, (4) burdensome rules and (5) fraud.[41]

An estimated 3–10% of all health care expenditures in the U.S. are fraudulent. In 2011, Medicare and Medicaid made $65 billion in improper payments (including both error and fraud). Government efforts to reduce fraud include $4 billion in fraudulent payments recovered by the Department of Justice and the FBI in 2012, longer jail sentences specified by the Affordable Care Act, and Senior Medicare Patrols—volunteers trained to identify and report fraud.[42]

In 2007, the Department of Justice and Health and Human Services formed the Medicare Fraud Strike Force to combat fraud through data analysis and increased community policing. As of May 2013, the Strike Force has charged more than 1,500 people for false billings of more than $5 billion. Medicare fraud often takes the form of kickbacks and money-laundering. Fraud schemes often take the form of billing for medically unnecessary services or services not rendered.[43]

Quality of care

There is significant debate regarding the quality of the U.S. healthcare system relative to those of other countries. Although there are advancements in the quality of care in America due to the acknowledgement of various health related topics such as how insurance plans are now mandated to include coverage for those with mental health and substance abuse disorders as well with the inability to deny a person who has preexisting conditions through the ACA,[44] there is still much that needs to be improved. Within the U.S., those who are a racial/ethnic minority along with those who poses a lower income have higher chances of experiencing a lower quality of care at higher cost. Despite the advancements with the ACA, this may discourage a person from seeking medical treatment.[45] Physicians for a National Health Program, a pro-universal single-payer system of health care advocacy group, has claimed that a free market solution to health care provides a lower quality of care, with higher mortality rates, than publicly funded systems.[46] The quality of health maintenance organizations and managed care have also been criticized by this same group.[47]

According to a 2000 study of the World Health Organization, publicly funded systems of industrial nations spend less on health care, both as a percentage of their GDP and per capita, and enjoy superior population-based health care outcomes.[48] However, conservative commentator David Gratzer and the Cato Institute, a libertarian think tank, have both criticized the WHO's comparison method for being biased; the WHO study marked down countries for having private or fee-paying health treatment and rated countries by comparison to their expected health care performance, rather than objectively comparing quality of care.[49][50]

Some medical researchers say that patient satisfaction surveys are a poor way to evaluate medical care. Researchers at the RAND Corporation and the Department of Veterans Affairs asked 236 elderly patients in two different managed care plans to rate their care, then examined care in medical records, as reported in Annals of Internal Medicine. There was no correlation. "Patient ratings of health care are easy to obtain and report, but do not accurately measure the technical quality of medical care," said John T. Chang, UCLA, lead author.[51][52][53]

Public opinion

The spring 2010 healthcare reform issue of Ms. magazine
The spring 2010 healthcare reform issue of Ms. magazine

Public opinion polls have shown a majority of the public supports various levels of government involvement in health care in the United States,[54] with stated preferences depending on how the question is asked.[55] Polls from Harvard University in 1988,[56] the Los Angeles Times in 1990,[57] and the Wall Street Journal in 1991[58] all showed strong support for a health care system compared to the system in Canada. More recently, however, polling support has declined for that sort of health care system,[54][55] with a 2007 Yahoo/AP poll showing 54% of respondents considered themselves supporters of "single-payer health care,"[59] a majority in favor of a number of reforms according to a joint poll with the Los Angeles Times and Bloomberg,[60] and a plurality of respondents in a 2009 poll for Time Magazine showed support for "a national single-payer plan similar to Medicare for all."[61] Polls by Rasmussen Reports in 2011[62] and 2012[63] showed pluralities opposed to single-payer health care. Many other polls show support for various levels of government involvement in health care, including polls from New York Times/CBS News[64][65] and Washington Post/ABC News,[66] showing favorability for a form of national health insurance. The Kaiser Family Foundation[67] showed 58% in favor of a national health plan such as Medicare-for-all in 2009, with support around the same level from 2017 to April 2019, when 56% said they supported it.[68][69] A Quinnipiac poll in three states in 2008 found majority support for the government ensuring "that everyone in the United States has adequate health-care" among likely Democratic primary voters.[70]

A 2001 article in the public health journal Health Affairs studied fifty years of American public opinion of various health care plans and concluded that, while there appears to be general support of a "national health care plan," poll respondents "remain satisfied with their current medical arrangements, do not trust the federal government to do what is right, and do not favor a single-payer type of national health plan."[54] Politifact rated a 2009 statement by Michael Moore "false" when he stated that "[t]he majority actually want single-payer health care." According to Politifact, responses on these polls largely depend on the wording. For example, people respond more favorably when they are asked if they want a system "like Medicare".[55]

Uninsured Americans, with the numbers shown here from 1987 to 2008, are a major driver for reform efforts
Uninsured Americans, with the numbers shown here from 1987 to 2008, are a major driver for reform efforts

Alternatives and research directions

There are alternatives to the exchange-based market system which was enacted by the Patient Protection and Affordable Care Act which have been proposed in the past and continue to be proposed, such as a single-payer system and allowing health insurance to be regulated at the federal level.

In addition, the Patient Protection and Affordable Health Care Act of 2010 contained provisions which allows the Centers for Medicare and Medicaid Services (CMS) to undertake pilot projects which, if they are successful could be implemented in future.

Single-payer health care

A number of proposals have been made for a universal single-payer healthcare system in the United States, most recently the United States National Health Care Act, (popularly known as H.R. 676 or "Medicare for All") but none have achieved more political support than 20% congressional co-sponsorship. Advocates argue that preventative health care expenditures can save several hundreds of billions of dollars per year because publicly funded universal health care would benefit employers and consumers, that employers would benefit from a bigger pool of potential customers and that employers would likely pay less, and would be spared administrative costs of health care benefits. It is also argued that inequities between employers would be reduced.[71][72][73] Also, for example, cancer patients are more likely to be diagnosed at Stage I where curative treatment is typically a few outpatient visits, instead of at Stage III or later in an emergency room where treatment can involve years of hospitalization and is often terminal.[74][75] Others have estimated a long-term savings amounting to 40% of all national health expenditures due to preventative health care,[76] although estimates from the Congressional Budget Office and The New England Journal of Medicine have found that preventative care is more expensive.[77]

Any national system would be paid for in part through taxes replacing insurance premiums, but advocates also believe savings would be realized through preventative care and the elimination of insurance company overhead and hospital billing costs.[78] An analysis of a single-payer bill by the Physicians for a National Health Program estimated the immediate savings at $350 billion per year.[79] The Commonwealth Fund believes that, if the United States adopted a universal health care system, the mortality rate would improve and the country would save approximately $570 billion a year.[80]

Recent enactments of single-payer systems within individual states, such as in Vermont in 2011, may serve as living models supporting federal single-payer coverage.[81] The plan in Vermont, however, has failed.[82]

On June 1, 2017, in light of the recent Trump Administration’s efforts to repeal the Affordable Care Act, California Democratic Senator Ricardo Lara proposed a bill to establish single-payer healthcare within the state of California (SB 562), calling on fellow senators to act quickly in defense of healthcare. The legislation would implement “Medicare for All,” placing all levels of healthcare in the hands of the state. The bill proposed to the California Senate by Senator Lara lacked a method of funding required to finance the $400 billion-dollar policy. Despite this lack of foresight, the bill gained approval from the senate and will move on to await approval by the state assembly.[83]

In wake of the Affordable Care Act, the state of California has experienced the greatest rise in newly insured people compared to other states. Subsequently, the number of physicians under MediCal are not enough to meet the demand, therefore 25% of physicians care for 80% of patients who are covered through MediCal[84]

In the past, California has struggled to maintain healthcare effectiveness, due in part to its unstable budget and complex regulations. The state has a policy in place known as the Gann Limit, otherwise entitled proposition 98, which ensures that a portion of state funds are directed towards the education system. This limit would be exceeded if California raises taxes to fund the new system which would require $100 billion in tax revenue. In order to avoid legal dispute, voters would be required to amend proposition 98 and exempt healthcare funding from required educational contributions.[85] The state announced on August 1, 2017 that coverage for health insurance will increase by 12.5% in next year, threatening the coverage of 1.5 million people [86]

Public option

In January 2013, Representative Jan Schakowsky and 44 other U.S. House of Representatives Democrats introduced H.R. 261, the "Public Option Deficit Reduction Act" which would amend the 2010 Affordable Care Act to create a public option. The bill would set up a government-run health insurance plan with premiums 5% to 7% percent lower than private insurance. The Congressional Budget Office estimated it would reduce the United States public debt by $104 billion over 10 years.[87]

Balancing doctor supply and demand

The Medicare Graduate Medical Education program regulates the supply of medical doctors in the U.S.[88] By adjusting the reimbursement rates to establish more income equality among the medical professions, the effective cost of medical care can be lowered.

Bundled payments

A key project is one that could radically change the way the medical profession is paid for services under Medicare and Medicaid. The current system, which is also the prime system used by medical insurers is known as fee-for-service because the medical practitioner is paid only for the performance of medical procedures which, it is argued means that doctors have a financial incentive to do more tests (which generates more income) which may not be in the patients' best long-term interest. The current system encourages medical interventions such as surgeries and prescribed medicines (all of which carry some risk for the patient but increase revenues for the medical care industry) and does not reward other activities such as encouraging behavioral changes such as modifying dietary habits and quitting smoking, or follow-ups regarding prescribed regimes which could have better outcomes for the patient at a lower cost. The current fee-for-service system also rewards bad hospitals for bad service. Some[who?] have noted that the best hospitals have fewer re-admission rates than others, which benefits patients, but some of the worst hospitals have high re-admission rates which is bad for patients but is perversely rewarded under the fee-for-service system.

Projects at CMS are examining the possibility of rewarding health care providers through a process known as "bundled payments"[89] by which local doctors and hospitals in an area would be paid not on a fee for service basis but on a capitation system linked to outcomes. The areas with the best outcomes would get more. This system, it is argued, makes medical practitioners much more concerned to focus on activities that deliver real health benefits at a lower cost to the system by removing the perversities inherent in the fee-for-service system.

Though aimed as a model for health care funded by CMS, if the project is successful it is thought that the model could be followed by the commercial health insurance industry also.

Centers for Medicare and Medicaid Innovation

With the ACA improving the health of many by increasing the number of people who are insured, this is not the final stage for the ACA due to the push for a medicaid expansion reform. With the Democrats supporting the expansion and the Republicans against it, it was denied in the Supreme Court in the trial of NFIB vs Sebelius. The Court ruled that implementing taxes in order to pay for health insurance for all citizens was an unconstitutional exercise of Congress’s power under Article I.[90] If the expansion eventually succeeds, Medicaid would become a fully federal program with new federal eligibility standards. This would alleviate the responsibility of state governments to fund Medicaid.[91]

In addition to the reform for the medicaid expansion, there are additional reforms focused on addressing social determinants in the healthcare system through various programs and initiatives in order to reduce healthcare expenditures and improve health outcomes.

Programs and initiatives recognizing and addressing non-medical social needs have sprung from various sectors within healthcare, with emerging efforts made by multi-payer federal and state initiatives, medicaid initiatives led by states, or by health plans, as well as provider level actions.State and federal initiatives, primarily sponsored CMMI (Center for Medicare and Medicaid Innovation) a division of CMS, seek to address basic social needs within the context of the healthcare delivery system. CMMI initiatives like the 2016 "Accountable Health Communities" (AHC) model have been created to focus on connecting Medicare and Medicaid beneficiaries with community services to address health-related social needs, while providing funds to organizations so that they can systematically identify and address the health-related social needs of Medicare and Medicaid recipients through screening, referral, and community navigation services.[92] The model was officially implemented in 2017 and will be evaluated for its ability to affect cost of healthcare spending and reduce inpatient/outpatient utilization in 2022.[92][93] Under the AHC model, funds have been allocated towards developing a 10-item screening tool to identify 5 different patient need domains that can be addressed through community resources (housing instability, food insecurity, transportation difficulties, utility assistance needs, and interpersonal safety).[94] Increasing bodies of evidence suggest that addressing social needs can help stop their damaging health effects, but screening for social needs is not yet standard clinical practice. Applying this tool in the AHC model will help CMS evaluate the impact of local partnerships between healthcare providers and community organizations in advancing the aims of addressing the cost and quality of health care across all settings.[94] National recommendations around multi-dimension screening for social risk are not yet available since the evidence base to support such recommendations is highly under-developed at present. More research is still needed in this area to be able to demonstrate whether screening for social risk, and especially for multiple domains of social risk, will succeed in meeting the Wilson and Jungner screening criteria.[95]

Health plan specific initiatives

Due to how new CMMI initiatives are, evidence supporting the effectiveness of its various initiatives of reducing healthcare spending and improving health outcomes of patients is relatively small, but is expected to grow within the coming years as many of CMMI's programs and initiatives will be due for their programmatic performance evaluation.[93] However, it remains that there is more evidence of smaller scale initiatives in individual health plans/hospitals/clinics, as several health plans, hospitals, and clinics have sought out to address social determinants of health within their scope of care.[95]


Transportation is a key social determinant impacting patient outcomes with approximately 3.6 million individuals unable to receive the necessary medical care due to transportation barrier, according to recent study.[96] In addition, these 3.6 million experience multiple conditions at a much higher rate than those who have stable access to transportation. Many conditions that they face, however, can be managed if appropriate care is made available. For some conditions, this care is cost-effective and results in health care cost savings that outweigh added transportation costs.[96] without access to reliable, affordable, and convenient transportation, patients miss appointments and end up costing clinics money. According to a cross-study analysis, missed appointments and care delays cost the healthcare industry $150 billion each year.[97] Patients without transportation are also less likely to take medications as directed.[98] One study found that 65 percent of patients felt transportation assistance would enable them to fill prescriptions as directed after discharge.[98] According to a recent article published in the Journal of the American Medical Association, ridesharing services such as Lyft and Uber can improve that healthcare disparity and cut down on the $2.7 million the federal government spends each year on non-emergency medical transportation services.[99] To recover revenue and improve care quality, some health systems like MedStar Health and Denver Health Medical Center are teaming up with Uber, Lyft, and other ridesharing companies to connect patients with transportation.[99]


The University of Illinois Hospital, part of the University of Illinois Hospital & Health Sciences System, identified that large portion of the individuals with high rates of emergency department were also chronically homeless, and that these individuals were in the 10th decile for patient cost, with annual per patient expenses ranging from $51,000 to $533,000.[100] The University of Illinois partnered with a community group called the Center for Housing and Health to initiate the Better Health Through Housing initiative in 2015, an initiative that connected chronically homeless individuals with transitional housing and case managers. In partnering with the Center for Housing and Health, the University of Illinois Hospital saw participant healthcare costs fall 42 percent, and more recent studies have found that costs dropped by 61 percent. The hospital's emergency department reported a 35% reduction in use.[100]


Some health plans have chosen to address some SDOH within their own means by establishing programs that directly deal with a single risk factor. Studies show that malnutrition can lead to higher costs of care and extended hospital states with the average hospital stay costing nearly $2,000 per day.[101] Advocate Health Care, an accountable care organization in Chicago, Illinois, implemented a nutrition care program at four of its Chicago area hospitals, an initiative that resulted in more than $4.8 million in cost savings within 6 months due to shorter hospital states and lower readmission rates (reduced 30 day readmission rates by 27% and the average hospital stay by nearly two days).[101]

Trump administration efforts

Donald Trump was elected president on a platform that included a pledge to "repeal and replace" the Patient Protection and Affordable Care Act (commonly called the Affordable Care Act or Obamacare). Rather than making adjustments to the Affordable Care Act, President Trump is proposing the American Health Care Act (AHCA), which was developed by the House of Representatives. If passed, this new health care act would cause insurance and healthcare to return to the market potentially causing for 18 million Americans to become uninsured.[102] In addition to this, President Trump is pushing for a change in policies regarding "public charge" which would cause the public benefits such as health, nutrition, and housing programs that were previously excluded to count towards considering a person a public charge. By doing this, immigrants who use these resources would have their ability to obtain legal permanent resident status affected increasing their chance of being denied citizenship.[103] The administration has suggested that the AHCA is only part of its reform efforts. Other proposals include allowing interstate competition in the health insurance market.[citation needed]

Incentivizing health reimbursement arrangements is another goal.[104]

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Further reading

External links

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