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Time to Forge a Uniquely American Solution Born of Our Own Strengths and Diversity

Dreyfus, Andrew

The Journal of Ambulatory Care Management: July/September 2019 - Volume 42 - Issue 3 - p 150–152
doi: 10.1097/JAC.0000000000000294
Appreciations
Free

Blue Cross Blue Shield of Massachusetts, Boston.

Correspondence: Andrew Dreyfus, Blue Cross Blue Shield of Massachusetts, 101 Huntington Ave, Ste 1300, Boston, MA 02199.

Andrew Dreyfus is president and CEO of Blue Cross Blue Shield of Massachusetts, which provides health insurance coverage for 2.8 million people. He served in the Executive Office of Human Services during the Dukakis administration's initial fight for health reform, and led the Blue Cross Blue Shield Foundation when it produced a “roadmap” for universal coverage that later became a blueprint for state legislation.

The author has disclosed that he has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

THIS ISSUE is dedicated to my longtime friend and colleague Rob Restuccia. Rob was known as a visionary who helped lead the fight for health justice in our country. And yet the defining feature of Rob's approach to advocacy was not his fierce idealism, but rather his gift for bringing people together with pragmatism and purpose. Rob recognized and nurtured the powerful strengths of seemingly opposing forces in advocacy, government, and business. That's a lesson our current elected officials and health care advocates can take to heart in thinking about the path to universal coverage.

Today, we are sharply divided on ideological grounds over health coverage. Some advocate for a system that is funded entirely by the government, and others for a system run via the private market. Both sides fail to see we currently have a system that is a hybrid of both.

Our divide must not prevent us from forging a uniquely American solution to health reform, one that offers the breadth of coverage of many European systems with the freedom to experiment and innovate that our own system nurtures.

There are a few bold but important steps we can take.

First, we can embrace the potential of the Affordable Care Act (ACA). If every state opted for the ACA's Medicaid expansion program, we would be able to cut the number of uninsured by half. Expansion in Texas and Florida alone would cut the number by 20%.

Five percent of patients generate 50% of spending, which causes premiums to increase for all. To address that, we can fund public reinsurance programs to stabilize the insurance market in the face of high claims from that small minority and make coverage more available and affordable for the 95%.

We can restore federal cost-sharing reductions to lower the amount low-income members have to pay for deductibles, co-payments, and coinsurance.

We also can agree as a society that it is unacceptable to leave 30 million people without health insurance, and we can fund new public programs to cover undocumented immigrants and others who fall through our safety nets.

And we can agree that we do not want a carbon copy of any other country's health care model.

The first step is recognizing that the conventional distinction between a system run through market dynamics and one run via government regulations is a false dichotomy.

For instance, in Germany, residents receive health insurance from an array of not-for-profit insurers who pay private clinicians and hospitals. The cost is covered by workers and employers via payroll taxes, and the government pays for coverage for the unemployed and for children.

In Canada, health care is government-financed in a single-payer system, but providers are private.

In Britain, health care is financed by the government through taxes and largely delivered by government-paid providers—but there are some private providers as well, and some members of the public opt for private health insurance to supplement the government system.

In the United States of course, we have a fragmented system.

Health care for about half of our population is paid for directly by the government, financed by taxpayers: Our veterans receive care that is government-financed and government-delivered, a system akin to that in the United Kingdom. Low-income Americans on Medicaid, children on CHIP, and seniors on Medicare receive health care paid for by taxes and provided by private physicians, a model similar to Canada's. Most American workers get insurance through employers and care via private doctors and hospitals, as they would in Germany.

And then there are the approximately 15% of Americans who lack health insurance, struggle to pay for their health care out of pocket, and often end up buried in debt, a system that is not really a system but is more akin to the cruel struggles faced by the destitute in developing countries.

Amid its flaws, our country also attracts extraordinary scientific talent from around the globe, providing a vibrant environment for innovation and robust incentives for discovery. Our researchers churn out medical advances that benefit patients all over the world. Our physicians and hospitals offer access to the most advanced diagnostic and treatment tools on the planet. These are not gifts to be squandered.

We need a solution born out of our own strengths and diversity.

Massachusetts offers one path.

Rather than creating a budget for European-style universally government-funded health care, our state sets a benchmark for cost increases each year and plans such as ours negotiate budgets with hospitals and providers. The system puts cost in the hands of the market and care in hands of clinicians, not the government. And it has worked.

Every year since 2010, Massachusetts has outperformed the rest of the country on constraining cost growth. Much of that success has been driven by our state's adoption of global payments, which my plan was the first to launch in 2009. Our program has become a national model by rewarding participating physicians for improved quality, outcomes, and costs—rather than simply fees for services. That is the kind of innovation that the private market makes possible.

With a health insurance mandate and a large pool of public funding for low-income people, our percentage of uninsured residents has been cut to 3%, the lowest in the nation by far. Expanded coverage has improved access to needed care and increased the use of preventive care. Our ranking is exemplary for public health measures including mortality, suicide rate, smoking, infant mortality, and adult obesity.

How did this system take shape? We overcame our ingrained divisions.

As in the rest of America, our community and political leaders span a broad ideological spectrum. But—assisted by dedicated thought leaders such as Rob Restuccia and others—public officials, consumers, employers, physicians, labor, and health plans set aside ideology and self-interest to unite around a commitment to shared responsibility in health care.

The fight was not won overnight. It began in the late 1980s, under Democratic Gov. Michael Dukakis. It was not until 2006 that Republican Gov. Mitt Romney, with support from a broad coalition of business and health care interests, joined with Democratic legislative leaders, Sen. Ted Kennedy, and Bush administration officials to forge our state's groundbreaking law. That collaborative work has continued ever since, through multiple administrations, as Republicans and Democrats have worked together on a local and national level to improve health care and health coverage in our state.

With that spirit of determination and pragmatism, we can and should tackle the challenges in our wider national system as well.

Everyone should have health care in our country. And it should be affordable and high-quality.

Health care for all is within reach, as Rob Restuccia fought his whole life to prove. Let's not allow false policy choices or politics to slow our progress.

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