What Values and Priorities Mean for Health Reform

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      Views regarding the government’s role in improving the system are sharply divided along partisan lines, in keeping with evidence from many polls about political divisions in support for particular health policy provisions. Such divisions suggest that the prospects for large-scale reforms remain limited by the political landscape. A successful approach might be to extend insurance coverage protections while maintaining a range of insurance plan designs and private-sector incentives to drive innovation. This approach differs from those taken by many other countries (and touted in many reform proposals), but is in fact the core approach in Medicare Advantage, Medicare Part D, and the Affordable Care Act — and it seems to match Americans’ priorities.

      A natural question is whether these views have been substantially affected by Covid. In fact, our survey results from February and May were quite similar, which suggests that we may be capturing durable, fundamental preferences about health care and its delivery.

      Political slogans simply don’t capture the types of reforms that are likely to achieve a nuanced set of objectives. Like the health care system itself, Americans’ priorities for it are complicated. Successful reforms must be informed by those priorities, but the trade-offs involved mean that they’re unlikely to take “simple,” polarized forms. The good news is that there are policy options available that preserve choice and promote innovation while honoring our shared commitment to making lifesaving care available to all.

      Comment by Don McCanne of PNHP: What do the American people really want out of their health care system? The authors of this NEJM article suggest that the prevailing rhetoric – such as “Medicare for All” and “Repeal and Replace” – may be simple and appealing, but that it is vague enough that it obscures the various health policy trade-offs involved. Of course, since they are simply labels, they communicate very little, but that does not mean that people do not have general concepts in mind when they use these terms. One term refers to a government-run health insurance program in which everyone is included, and the other refers to a program relying primarily on the private market for the financing of health care in which coverage is not guaranteed but is based on the ability to pay. These two approaches are driven more by ideology rather than by the specifics of beneficial health policy.

      Policy considerations are fairly obvious. Should a health care financing system be designed to include everyone? Make it affordable for each of us? Provide us with choices of our hospitals and health care professionals? And so forth. Most people would agree that we should have a better health care system that’s affordable for all of us. But some people are hung up on the ideology. Should the system be based on social solidarity or based on free market competition?

      Using an AP/NORC survey, people were asked about concerns about their own insurance coverage and concerns about Americans who did not have insurance coverage. Both Democrats and Republicans showed some concern about both, but they were more concerned about others having coverage than having their own. On this policy issue, individuals from both major parties seemed to be altruistic, though the Democrats were more so. When asked about plan variation in costs and coverage, there was no dominant view and no partisan preference. Yet Democrats greatly preferred to have the government spend more on health care, paid through taxes, whereas only about one-third of Republicans agreed. Also, Democrats had more faith in the government to expand access, improve quality and reduce costs than did the Republicans. Obviously, ideology does influence policy.

      Since the authors are noted, influential authorities in the policy community, it is helpful to try to extract from this article what their approach would be. Policies may be beneficial or detrimental, which explains why there is little agreement when individuals are required to choose from various trade-offs (e.g., exposed to financial hardship or being denied benefits). On the other hand, political ideology is more fixed and thus drives greater divides.

      In this case, the authors reject one-size-fits-all single-payer, presumably because people should have choices between the policy trade-offs, so theoretically we can ignore the ideological preference for a program that is taxpayer financed and publicly administered. Then the authors mention private insurance programs that are at least partially publicly financed to demonstrate their preference: Medicare Advantage, Medicare Part D, and the private plans of the Affordable Care Act, claiming that these seem to match Americans’ priorities. Is introducing into a public program the use of private insurance a beneficial policy preference or an ideological preference? Beneficial for whom? Not the patients.

      What they miss is that policy trade-offs do not necessarily require giving away beneficial features. As an example, you do not have to reduce benefits to eliminate excessive cost sharing. You can trade off the profound administrative waste created by our private insurance industry in order to have a full benefit package without the necessity of including the financial barriers of cost sharing. And ideology? Why would we want to screw up beneficial health care policies with nutty right-wing innovations?

      Jesus: Hey, Dad? God: Yes, Son? Jesus: Western civilization followed me home. Can I keep it? God: Certainly not! And put it down this minute--you don't know where it's been! Tom Robbins in Another Roadside Attraction

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