Threading the Needle Between the Affordable Care Act (ACA) and Medicare for All
This issue of the journal is important to me on both a professional and personal level. The issue theme is “threading the needle between the Affordable Care Act (ACA) and Medicare for All.” All of us in the field know that the challenges to achieving universal affordable quality health insurance coverage (hereafter universal coverage) in the United States are formidable. The authors in this issue have covered virtually all the challenges. Kevin Fiscella highlights the importance in any update of the ACA or passing Medicare for All of focusing on value and equity. He points to the need for a small number of metrics when measuring outcomes of care or value. Professor Fiscella among other authors in this issue emphasize that without a significant improvement in value (outcomes quality divided by cost), the increasing cost of the American health care system can never result in universal coverage. Dr Antos in his contribution points to the fact, for example, that Accountable Care Organizations are not the magic bullet (pace to those who believe that they were not implemented appropriately by the Obama administration) we hoped for in cost control. Cost control is a must have ingredient if we are to pursue value for the American health system. Richard Kirsch highlights a specific approach that essentially federalizes the Medicaid program, an approach that potentially links value and equity.
John Auerbach, in his contribution, emphasizes the need for a focus on prevention in any future effort to have implement universal coverage. Fiscella's salutary emphasis on equity recognizes the need for policymakers to recognize the importance of socioeconomic disparities (SED). We need to remember that recognition of the importance of SED is by no means a given with opposition coming from both the left and the right. In fact, the Center for Medicare and Medicaid Services (CMS) under the Obama administration was opposed to any recognition of this critical variable; legislation was required and indeed it was passed forcing the Obama administration to take into account SED in, for example, the calculation of penalties for excess readmissions.
Anthony Wright points to the importance of state wide experimentation. Trial of major health care initiatives or “balloons” at a state level is an important part of American health policy tradition. Diagnosis Related Groups (DRGs), recognized as one of the most significant regulatory interventions in health care throughout the industrialized world, began as an experiment in the State of New Jersey. Rich Averill, one of the leads in the original development of the DRGs more than 50 years ago, and colleagues in this issue point to a pro-competitive approach to DRG implementation which the federal government could implement as a way forward to improving value in at least the hospital sector. And states with the active involvement of Rob Restuccia, John McDonough and many others were instrumental in the passage of an early version of the ACA, first in Massachusetts under a Republican governor, thus earning the name of Romneycare. In his contribution, Andrew Dreyfus points to the singular role that Massachusetts has in fact played in health policy innovation that has spread throughout the country. It is no accident that Massachusetts has the lowest number of uninsured in the country.
The importance of this issue of the journal lies not only in the breadth of the health policy articles, but also in the recognition of the impact that individuals can have on specific pieces of legislation. Rob Restuccia who passed away earlier this year was one of those individuals. There are a number of appreciations in this issue and I hope that readers will carefully examine them all for lessons learned. I knew Rob for more than 30 years and worked with him actively as a member of the Health Care for All board of directors. I can personally attest to the veracity of virtually all of the comments made about him personally and what he accomplished. Michael Miller highlighted several important lessons learned that we can gather from Rob's decades long effort to enact universal coverage. Rob's efforts were “in deed” in the spirit of Fiscella and others in this issue who emphasized value, coverage and equity. Miller emphasizes the consumer voice as point number one in connecting value, coverage, and equity. Alas, while I wish we could simply rely on the voice of the consumer, it is in my mind necessary but hardly sufficient. Miller points out how Rob and many others worked to create alliances with segments of the health care industry – doctors, nurses, hospitals, and, yes, even the insurance industry. At this point in history, we will not be able to convince the device manufacturers and pharmaceutical industries. However, if we cannot at least peel off some parts of the health care industry and business in general (maybe Amazon??), there is no chance of enacting universal coverage. We need allies, as Michael Miller points out, as consumers cannot do it by themselves. And Rob Restuccia always believed that allies can be found everywhere.
Carl Atkins in this issue summarizes the positive elements of a single payer approach. I do believe that the presence of single payer advocates in Congress and throughout the U.S. can create positive pressure to push for the best possible approach to universal coverage. The challenge of single payer advocates will be to appreciate the political choices in any single payer approach and know when to realize that they've pushed the envelope as far as they can, without risking coming away from the table with nothing to show for their efforts. While I realize that some single payer advocates have an all or nothing approach, I am hopeful that political pressure will convince the majority of single payer advocates the merits of a major step forward toward universal affordable quality insurance coverage. This recognition represents a political question and challenge. The bottom line from a political point of view is that Democrats need to win in 2020 the Presidency and both Houses of Congress for universal coverage to even be on the table for legislative consideration. I am hoping that a temporary tactical truce between all universal coverage advocates can occur through the 2020 elections. To foster this truce, the leadership of the House of Representatives should bring the two sides together and pass legislation in the House that addresses many of the policy questions that this issue of the Journal raises. In this manner if we succeed in having a President and leadership in both sides of Congress committed to universal coverage after the 2020 elections, lawmakers will have worked through before the 2020 elections many of the policy questions that need resolution for universal coverage to occur.
Antos and Wilensky focus on market-based reforms in this issue of the Journal. Recently Antos and Capretta encourage Republicans to support Medicaid expansion to all states, a plan which would make a significant dent in the uninsured. In this same article, they opine: “Republicans keep searching for a politically safe silver bullet that slays Obamacare and yet leaves everyone happy. That plan doesn't exist.” (Antos & Capretta, 2019). I wonder why the Republicans don't support Antos, Capretta and Wilensky; adopting their recommendations would immediately take the health care issue off the political table. I've come to the conclusion that major Republican office holders realize that a significant percentage of Republican voters don't believe that health care is a right for all in a decent society even if it is delivered in a market dominated system. What about those Republicans who do believe in the obligations of a decent society? Depending on how important health care is as a national political issue, these voters are up for grabs in 2020. In my new political consulting role (www.asknursesdoctors.com), I've already met some of the, for example, doctors and nurses who crossed party lines and voted for the idea of health care as a right in any decent society. As Michael Miller summarizes, Rob Restuccia showed me and others the way to convince these voters: focus on the consumer perspective, create allies even in the most unlikely places.
Anthony Wright in this issue emphasizes the need for moving from either/or to yes/and. To make that move requires leaders, such as Rob, who can engender the popular support needed to pass comprehensive reform while mitigating the inevitable industry opposition. In this issue of the Journal, Kirsch said it very well: “The common declaration that “all other [Western, developed] countries have single-payer” is not at all true. What is true is that all of these countries make health care a right and a public good. They do so in a variety of ways, from the government providing health care directly (Great Britain), to single-payer, government health insurance (Canada), to community or employer-based insurance funds (Germany) to highly-regulated private insurance (Switzerland).”
What will it to take to thread that needle and definitively move us as a country to health care as a right and public good – a position poll after poll demonstrates to be supported by a significant majority of Americans. This issue of the journal offers in both personal and policy terms most of the paths that we can pursue as we go forward. Now lets make it happen!
—Norbert I. Goldfield, MD