Much of the recent discussion about replacing the Affordable Care Act (ACA) has centered on questions of fairness: How fair are high insurance premiums for the healthy young population? How fair is Medicaid expansion in some states but not others? How fair is government support for purchase of insurance by low-income individuals? These and other arguments about fairness reminded me of some of my earliest discussions about fairness when I was a child. I remember complaining to my parents that my friends could stay out playing in the street long after I was tucked away in bed. I could hear their shouts and laughs as they threw a football in front of our house. “It isn’t fair,” I would say.
“Life’s not fair,” my father would respond. He would go on to describe the many examples of unfairness in life—friends killed in World War II, family members who never had the opportunity to go to college, restrictions on where people could live based upon race or religion. Later on, after I became a doctor, I developed my own list of examples of unfairness—the family driving home from church on Christmas Eve wiped out by a drunk driver who was going the wrong way on a freeway, the undocumented immigrant with leukemia sent back to Mexico to get treatment that would be inferior to what he would have gotten if he were a U.S. citizen, the newborn whose mother was a drug addict suffering from drug withdrawal. I was surrounded by examples of unfairness in health care.
As a young emergency physician in training I would witness patients transferred from a private hospital to our county hospital because they lacked insurance; sometimes the delays in care that occurred could lead to complications or even death. The problem of transfer of unstable patients became so serious that in 1986 Congress passed a law now known as the Emergency Medical Treatment and Labor Act to limit and regulate the risk of emergency transfers.1 While this legislation largely stopped the most egregious transfers of acutely ill or injured patients and guaranteed access to care for emergency conditions, it did not address care for chronic illnesses or preventive care. Over the years I would see patients with hypertension who had developed kidney failure or heart failure because they had not treated their chronic hypertension due to a lack of insurance to help pay for medication.
The ACA was intended to partly address access to care for those with ongoing chronic conditions through extending insurance coverage to millions of people who had been unable to afford it. At the time the ACA was passed there were about 50 million people in the United States who were uninsured. Having so many people without insurance was not only unfair. It also increased expenses for medical care when uninsured patients developed complications that could have been prevented if their chronic conditions had been treated expeditiously. With the implementation of the ACA about 20 million people gained health care coverage either from Medicaid expansion or health insurance.
These improvements in insurance coverage reduced unfairness in the health care system related to health insurance coverage, yet unfairness was one of the major complaints about the ACA described by people interviewed by Gordon et al2 in an article in this issue of Academic Medicine. Gordon et al rode bicycles across the country before the 2016 election to gather the opinions about the ACA of people they met along the route. The expressions of unfairness were exemplified by one interviewee’s question: “Why should I have to pay for other people’s problems?” Other concerns that interviewees raised were the increasing cost of health insurance and the government’s intrusion into individual decisions about the type of insurance that could be purchased. These views about the unfairness of the ACA have surfaced in discussions about repealing and replacing the ACA. There have also been questions raised about whether the ACA actually improved health care coverage and access to care, and whether it improved health.
Sommers3 in this issue addresses some of these questions. He describes three lessons about how health insurance affects patients and the role of the ACA:
- Lesson 1. Coverage can be a matter of life or death. Sommers notes that the ACA could be saving as many as 24,000 lives per year.
- Lesson 2. The ACA has succeeded in expanding coverage and access to care. Sommers states that 20 million more Americans have health insurance since the passage of the ACA.
- Lesson 3. Challenges in coverage and access remain. Sommers cautions that disruptions in insurance can have an adverse effect on continuity and quality of health care.
Sommers ends his Invited Commentary by noting that the numerous research findings that support the ACA do not appear to be known by the public or policy makers, and he urges the use of evidence in considering any changes in health policy.
Kirch and Ast4 in this issue reiterate Sommers’s plea for evidence-based health policy. In their Invited Commentary they maintain that
the importance of scientific evidence to advancing health care cannot be understated. Scientists and physicians must continue to underscore the value of science as a critical informant for health policy, as they pursue additional evidence that can provide the key to solving academic medicine’s pressing questions.
They go on to provide an ethics-based framework for the analysis of health policy proposals, cautioning that any policies that would reduce health insurance coverage or worsen the health outcomes of individuals or populations would violate ethical principles, either of beneficence or of nonmalfeasance.
If the ACA has improved insurance coverage, why did those whom Gordon et al interviewed complain about its unfairness? I believe part of the answer may be related to the skewed distribution of health care spending. Cohen and Yu5 demonstrate that in 2009, 1% of the U.S. population were responsible for 21.8% of total health care expenditures, with a mean expenditure of $90,061 per person, while 50% of the population were responsible for only 3.1% of total health care spending, with a mean of $232. I suspect that the people that Gordon et al met in coffee shops and along the road were mostly the healthy half of the population who were paying what they felt were high premiums to support the health care needs of the sickest 1%. Is this unfair? It certainly seems that way to those who are young and healthy.
Many of the proposals for replacement of the ACA have involved changes that would reduce the insurance premiums for the young and healthy population. Unfortunately, reducing premiums for some young and healthy people would shift the burden to the older and sicker population. Those are the same people who, when they were young and healthy, supported the health care needs of the older generations. Was that fair? As I mentioned at the outset, health and illness are fundamentally unfair. Some people will get cancer and have high expenses while others live a long and healthy life and die suddenly of a heart attack without incurring any expenses. People who have high expenses tend to continue to have high expenses and those with low expenses maintain low expenses, both in the U.S. health care system and in Canada’s,6 which has a governmental payment system for health care. In the United States, research has shown differences in longevity related to income and geographical location7; these could be considered evidence of unfairness. And there are increased risks for health problems for those who smoke, drink alcohol excessively, or use drugs. How treatments of the health problems associated with such risks should be paid for is a cultural and political question. While most developed countries have decided that health and health care are public goods requiring governmental financing and oversight, the United States continues to struggle with the role of government in health care.
Over the past two years, Academic Medicine has published perspectives from two different parts of the political spectrum about the role of government in health care as part of its New Conversations series. Antos8 provided a conservative perspective, and many of his ideas have been incorporated into proposals to replace the ACA. He advocates a competitive market-based approach to reduce health care spending through aligning the incentives for providers and patients and by offering more flexible government regulation and more information to patients. He would limit federal subsidies for health care coverage, reform Medicare through a premium support structure, encourage payment reform in Medicare through more use of the types of capitated payments used in Medicare Advantage programs, move Medicaid programs to block grants or a per capita subsidy, change tax treatment of health insurance, reduce government regulation of health insurance, and provide more consumer choice. For those interested in understanding the basis for many current Republican proposals to replace the ACA, the Antos article gives a clear and understandable summary.
Tom Daschle,9 former Democratic Senate Majority leader, identified five transformative forces in health care in his Invited Commentary in 2015. Two of these forces are (1) the need for greater transparency and greater involvement of consumers and (2) changes in health care payment models to move from fee for service to bundled payment and global payments. These were two areas also identified by Antos with very similar recommendations, suggesting the opportunity for bipartisan agreement. Daschle also identified the promise of Big Data, an emphasis on wellness, and changes in scope of practice to encourage team-based care. These are all ideas that could be compatible with Republican health reform proposals. While recent political debates about reform of the ACA have been contentious and concentrated on philosophical differences, I see the opportunity for potential collaboration based upon the concepts in these articles by two leading voices of health reform.
Political and policy discussions will unfold in their own time and dynamic. In the meantime, there are things that physicians and other health professionals can and should consider to improve the health system.
Address the cost of health care
First of all, the cost of health care must be addressed. Both political parties agree with this priority, as do health services researchers like Sommers. The United States currently spends more money per capita for health care than any other country, but the quality of care lags behind that of other developed countries. With an aging population, the United States can anticipate continued increases in health care spending. Medicare and Medicaid programs are projected to continue to grow, with their increasing spending crowding out other critical governmental programs. This is why many current proposals concerning the replacement of the ACA have included caps on the federal government’s support of Medicaid. Antos has also suggested similar capping of federal spending in Medicare through a premium support system, although that may not be currently politically feasible. It is clear that these two government health care programs are creating serious financial stress for the U.S. budget.
Physicians and other health professionals whose patient care decisions lead to spending on prescription medicines, performance of surgery, radiologic and laboratory testing, and hospitalization need to be part of the solution in reducing health care spending. We in academic medicine can foster their involvement by training our students and residents to reduce unnecessary care. We can also carry out research programs to identify innovations that can reduce spending and improve quality. And we can redesign our care delivery systems to reduce hospitalization for those with chronic illness, using interprofessional ambulatory care teams. We can do all this without waiting for comprehensive political solutions. Changes in the payment system are under way, and education can augment the behavior changes they will encourage. We can also improve transparency about the costs of various treatment options and pass on the information to patients and providers to help make shared decisions about high-value care options.
Improve the quality of care
We should also focus more effort on improvements in health care quality, an area in which the United States has not been a leader despite high spending on health care. This needs to change. While a major focus of health system change would be to reduce health care spending, there is a risk that lowering spending would lead to reduced quality and/or access. Current efforts to measure and reward quality are at an early stage. The National Academy of Medicine10 has published a set of core metrics for health and health care that could guide efforts to make systems-wide quality improvement. In addition, there needs to be investment in the science of quality measurement and training of physicians and other health professionals in how to improve quality at every level of the health care system. With the passage of the Medicare Access and CHIP Reauthorization Act of 2015, the United States moved aggressively into pay-for-performance for physicians. Clearly, we need to prepare students and residents to make quality improvement an integral part of their professional activities.
Improve fairness in health care
I also suggest that we continue to try improving fairness in health care. As I noted earlier, achieving fairness in health care is difficult because health care problems and health care spending are not evenly distributed. However, the health and well-being of the population are critical to the safety, security, and economic productivity of the country, which is a reason that many believe that protecting the most vulnerable members of our population is a responsibility of government.
For these reasons, I believe that an insurance system that provides access to high-quality, affordable health care for all should be a priority. Perhaps everyone could enter the health insurance system at birth and remain in it for life. There could be incentives for early joining and continuing to pay premiums as there are for life insurance; this approach could encourage everyone to participate and would lower premiums for everyone. In this way, there would be no gaming of the system by those who do not buy insurance until becoming ill, nor would there be refusals to cover a person who developed a chronic disease.
This kind of insurance system would account for the skewed distribution of health care spending by a small part of the population. None of us knows when or if he or she will become one of the 1% of the population responsible for over 20% of health care spending. At the same time, we as a nation must limit what we spend on health care and base spending on the effectiveness of treatment and the resources that our population can allocate to health care. Such decisions should be made with community discussion, informed with expert advice, and based upon our values of health equity. While we can acknowledge that life and health are not fair, as a just society we can take steps to limit the suffering and other burdens that accompany an illness or injury by providing access to high-quality health care for our population.
While a universal health insurance program may not be politically feasible today, we can start down that road by encouraging our students to commit to the care of all patients, regardless of insurance status. Residency education is financed with funds from Medicare, Medicaid, and the Veterans Health Administration, and a commitment by all our residency graduates to care for all patients from these programs as well as those without coverage would appear to be a fair exchange for the government’s support of training.
Advocacy Based Upon Values, Truth, and Stories
In this issue Levinsohn et al,11 a group of medical students, deliver a call to action for physicians and other health professionals to become involved in political advocacy related to the ACA. They remind us that there is an urgent need to share with our patients, our colleagues, and our political leaders what health services research has shown about the ACA and what we have witnessed through our own experience, which includes the powerful stories of our patients and their care. Their passion, informed by their values and the scientific evidence, gives me hope that our community can make its voices heard over the din of misinformation and misunderstanding. Values and truth matter. And while I recognize that fairness in health care may be an elusive goal, it is one worth fighting for with our values, truth, and stories.
David P. Sklar, MD