How do we create a high-value health care system?

Karen Schneider

Mercy Sr. Karen Schneider, a pediatrician, left, talks with the mother of a child in the emergency room at Johns Hopkins Hospital in Baltimore in 2014. (CNS/Bob Roller)

by Michael Panicola

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2017 has been a tumultuous year in health care in light of the repeated, failed attempts by Republicans to repeal and replace the Patient Protection and Affordable Care Act, known colloquially as Obamacare. This has caused uncertainty in insurance markets, paralyzed health care providers and negatively impacted some of our most vulnerable members in society who purchase coverage through the health insurance marketplaces or participate in the Medicaid program. 

As the anniversary of Donald Trump's election as president of the United States approached, the NCR staff wondered if the calls to action that persisted immediately following the election remained as urgent. We identified several policy issues to explore and asked NCR reporters to interview key players about what has transpired since Nov. 8, 2016. The entire series can be found here.

Despite President Donald Trump's claims that we will have "great health care" and "take care of everyone," we are further away from those lofty aspirations than we were prior to his taking office.

As an alternative to "repeal and replace," Sens. Lamar Alexander (R-Tennessee) and Patty Murray (D-Washington) have drafted bipartisan legislation that will, among other things, help prop up the health insurance marketplaces and potentially ease the burden on individuals who will be affected by the president's decision to cut off government cost-sharing subsidies. However, given the current political environment and lack of common-good mentality among lawmakers, one cannot be assured it will pass.

Even if it does, the legislation is merely a temporary, partial solution to a complex problem that will give Congress two short years to address the more pressing question: How do we create a just, fiscally sustainable, high-value health care system that meets the varied needs of individuals and communities?

This question has occupied the minds of legislators and health policy experts for decades, but it has become increasingly urgent in recent years, given the rising costs of health care and the aging population within the United States. As reflected in the debates over the Affordable Care Act and recent Republican reform efforts, we will continue to flounder in our attempts to transform U.S. health care if we cannot agree on two sets of facts and find solutions to the underlying problems associated with them.

No matter where one falls on the ideological spectrum, the fact is that universal coverage, literally where everyone has health insurance for a defined set of covered benefits, is not only morally good but also makes eminent sense economically. As the experience and data from other countries prove, when virtually all people of a given region or nation are afforded coverage and care across the continuum, insurance risk is spread more evenly, health care is less costly, and the population is actually healthier than in the situation that exists now in the United States with patchwork coverage schemes and gaps in care. 

Claims that the U.S. has universal coverage because everyone has access to emergency services are patently false. Even if such claims were true, universal coverage through emergency rooms is the most costly, least effective way to provide health care to all.

Given the deep philosophical divide, Congress likely will never adopt legislation that provides universal coverage through a single-payer system, like Democratic Sen. Bernie Sanders of Vermont has proposed. As such, the next, perhaps best, option is to create viable health insurance marketplaces with the intent of covering as many people as possible by providing financial support based on income for those who do not receive health care insurance through employment or qualify for government programs such as Medicare or Medicaid.

This is what the Affordable Care Act tried to achieve by creating markets or exchanges designed to offer affordable, comprehensive coverage. Whether Obamacare is a success or a debacle may be debatable. What isn't open for debate is the fact that the uninsured rate in the U.S. is at a historic low and, for related and unrelated reasons, the growth of health care spending has slowed since the act became law.

Still, Obamacare hasn't gone far enough. Even under the best projections, with full congressional support for the law, more than 20 million would remain uninsured. Congress needs to put aside ideological differences and craft sweeping, bipartisan legislation that guarantees health care coverage for all. For this to happen, Republicans will need to get over their aversion to anything associated with Obamacare, including the health insurance marketplaces, which incidentally were a Republican-born idea, and embrace the fact that universal coverage makes sense for reasons that are core to Republican ideals. Democrats, for their part, will need to overcome the notion that the nation has an infinite amount of money to spend on health care and compromise on some of their own equally partisan views.

The U.S. health care delivery system is deeply flawed. We may say we have the best health care in the world, but the fact is our health care is inaccessible to many; fragmented, uncoordinated and inequitable to those who gain access; and unsustainable financially. Safety is questionable, and quality outcomes related to anything other than rescue medicine do not match those of other developed nations.


(Unsplash/Hush Naidoo)

A major reason for this, which often gets overlooked or downplayed, is that health care providers have a stake in sustaining an outdated, capital-intensive acute/specialty care infrastructure that perpetuates the access, cost and quality problems plaguing U.S. health care. Even if everyone in the U.S. had health insurance and access were unfettered, care would not dramatically improve from a cost or quality perspective because health care providers are conditioned to and get paid handsomely for providing expensive, reactive, and oftentimes ineffective and unnecessary care.

Redressing this problem requires a radical overhaul of the fee-for-service reimbursement system under which the current health care system works. In this system, health care providers get paid for how much they do, not for how well they do it.

While we have made strides in this area through the Affordable Care Act and subsequent bipartisan legislation aimed mostly at physicians, change related to provider payments has not occurred to the extent needed to transform behavior. This overhaul will need congressional action.

If we have any chance of creating a better health system in the United States, legislation has to be enacted that incentivizes providers to organize their efforts around the most urgent community health needs, partner with diverse organizations to address social determinants of health, and strategically shift their focus, investments and activity to more accessible, convenient and low-cost structures and services centered around preventive and primary care, behavioral health, chronic disease management, and palliative and end-of-life care. This would truly create value and lead U.S. health care down a much different path, resulting in a fundamentally different-looking delivery system that would have a far greater impact on the health status of communities.

Admittedly, we need to do more than what's been proposed above to rectify the current problems and impending crisis in U.S. health care. However, without accepting the moral and practical urgency of universal health coverage and the equally critical need to overhaul health care financing and delivery, all reform efforts are doomed to fail.

[Michael Panicola has a doctorate in health care ethics from St. Louis University and is a theologian and ethicist working in Catholic health care.]

This story appears in the A Nation Under Trump feature series. View the full series.
A version of this story appeared in the Nov. 3-16, 2017 print issue.

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