Everyone should have access to healthcare. No one disputes that. But what does it mean? Is access defined by the right to have your healthcare needs met without sending you or your family into bankruptcy?
Or should the right of access be limited to the ability to purchase cheap, catastrophic coverage without the requirement that you do so?
Until we build a bipartisan consensus that access means everyone in our society has the right to obtain high-quality healthcare at an affordable price, we will never move beyond the sterile "repeal and replace" debate. We don't debate whether children should get a high school education. We provide taxpayer-financed public schools to achieve it.
Does that mean taxpayers must pay for everyone's healthcare, as single-payer advocates would like? No, it does not.
The 175 million Americans who receive employer-based coverage are mostly satisfied with what they have. However, support for the employer-based system is fraying due to the rise of high-deductible plans, which employers have deployed to keep their costs in check. The unfortunate side effect is that such plans have once again made healthcare affordability a top concern for many families.
What most employers don't understand, or have refused to engage in the public arena, is the extent to which their cost problem is due to uncompensated-care costs in other parts of the system. It's not just the cost of free care to the uninsured.
Employers and their employees also make up for shortfalls in government programs. Medicare pays about 7% less than the true cost of care, according to the Medicare Payment Advisory Commission. Medicaid pays even less.
That's why it was heartening last week to see the emergence of a bipartisan group of top healthcare leaders, former government officials, policy thinkers and patient advocates eager to work on access and affordability issues. Their mission is to "ensure that every single American has access to quality, affordable healthcare regardless of health status, social need, or income."
My hope for this new group is that the CEOs involved will put up enough money to flesh out some concrete ideas for how to achieve a financially sustainable healthcare system. The United States of Care should become a think tank that generates viable policy options capable of winning bipartisan support when the current fever paralyzing American politics abates.
The need could come as soon as 2021. Despite the Trump administration's efforts to cripple the Affordable Care Act, nearly 12 million people signed up for individual plans for 2018. The Medicaid expansion has taken hold in 31 states and the District of Columbia.
But there are still 28 million people uninsured in the U.S. And the bill for the cut-taxes-and-spend policies of the current Congress will eventually come due. When it does, entitlement reform, as they like to call it inside the Beltway, will be on the agenda.
Here's my short list of ideas that this new group should explore to be ready for when that time comes:
- Federalize the portion of Medicaid that provides health insurance; integrate it with the exchange-based individual insurance markets; peg its provider rates to Medicare, just like Medicare Advantage. Pay for it with a national, broad-based, value-added tax, which will give states major tax relief.
- Scrap fee-for-service medicine in all government programs and move to universal capitated payments to provider groups managed by regulated private insurers. Limit increases in a planned fashion over time so providers can minimize disruption while eliminating waste in the system.
- Allow Medicare to become the public option that competes with private insurers in every market and becomes the default insurer in markets where private insurers do not want to compete.
- Develop ways of delivering meaningful price and quality transparency to patients in real time, which will facilitate competition in local markets.
- Send every member of Congress to Germany to see how its health system works.