Beyond the ACA: Toward a Health Care System That Works for All of Us

February 1, 2016

The Democratic presidential debates have brought welcome attention to the question of how we can build on the Affordable Care Act to realize the goal of quality, affordable health care for all. It’s a refreshing and timely break from the Republicans’ tired pledges to repeal Obamacare, a radical right stance that is supported by every Republican candidate but only one out of three voters.

In many ways, the health debate between Clinton and Sanders is really less about health policy than about the entire conception of their campaigns: Clinton the pragmatic incrementalist and Sanders the bold visionary. But neither of the two candidates is focused on measures, incremental or bold, that move our health care system to focus on promoting good health, demanding that health care providers get paid for quality care, or reducing racial inequities in health care.

I’ve just written a paper, commissioned by the Universal Health Care Foundation of Connecticut, which is all about bold incrementalism. I lay out ambitious polices, building on the ACA and the current changes taking place in health care, aimed at getting to quality affordable health care for all and promoting good health, not just good health care.

I start with the pragmatic assumption that we will not be jumping from the Affordable Care Act to a fully publicly financed health care system. But even if America rallied behind Sanders’s political revolution and enacted Medicare for All—which I would welcome!—we would still need to refocus our health care system on providing high-value care and promoting health for all instead of the wasteful treatment focus of Medicare’s current fee-for-service model.

Medicare for All, as Sanders proposes it, would solve the two most glaring problems that remain after the ACA: the 29 million people who remain uninsured and skyrocketing out-of-pocket costs. Clinton’s “plan”—no details, just intentions—barely mentions expanding coverage to the millions who remain uninsured, focusing instead on pledges (no actual proposals) to lower deductibles and drug prices.

Actually, the one candidate who makes a number of serious proposals to expand coverage, improve affordability, and focus on quality, community health, and racial equity is O’Malley. As the Governor of Maryland, which has a long and ongoing history of innovation in health care delivery, O’Malley is clearly steeped in the major changes occurring in health care and how to address them. He could be a good candidate for the next Secretary of Health and Human Services.

While the public debate focuses on coverage and affordability, there are seismic changes happening in how we organize the delivery of health care. The visible part of the transformation, the iceberg above the surface, is mega-health insurance and hospital mergers. Like other icebergs, they look scary: bigger corporations jacking up prices to increase profits while consumers have fewer and fewer choices. People who need health care the most—those with chronic illness and disabilities, the elderly—are also likely to be hurt the most.

Ironically, though, concentration could offer the opportunity for more effective and simplified regulation. Concentration could facilitate the treatment of health care as the public good it truly is, rather than as a market good. Regulatory policies to control costs and increase quality should be easier to design and enforce if there are fewer entities to oversee and influence.

The ACA is already illustrating how government payers can have a positive impact. It is accelerating the movement of the American health care system from a focus on providing more care—needed or not—to providing quality care. By using the purchasing power of Medicare, our national health insurance program for seniors and people with disabilities, the ACA has begun paying hospitals and doctors more when they reduce costs while increasing quality, and paying them less when they provide poor quality care. In some states, Medicaid is beginning to drive the transformation with a focus on primary care and community health.

Government payers are not alone. Major employers are demanding better value from the health care delivered to their employees. Private insurers are testing programs for the chronically ill that improve health while saving money. Hospital systems and large medical groups are organizing large integrated care networks to deliver better care at lower cost.

Which of these competing versions of the concentration in health care will prevail—concentration for the sake of larger profits or concentration for the sake of better, more cost-effective care and improved health?

It is up to those who champion health care as a human right and a public good to build from the foundation of the ACA toward a health care system focused on affordable high-quality care—one that is directed toward not just good health treatment but good health.

I offer Beyond the ACA: Moving Toward a Health Care System that Works for All of Us as a roadmap. I paint a picture of the changing health care landscape so that organizers and advocates can understand the shifting terrain. I propose polices for a health care system that covers every person living in our country, is affordable to the country and to individuals, is high-quality, including for people with chronic illnesses, promotes racial equity in access and quality, and is focused on population and community health. More than 20 specific policies are outlined to:

  • Make sure that good insurance coverage is affordable and available to all of us.
  • Make sure we can afford to go to the doctor when needed, by eliminating deductibles and lowering co-payments.
  • Put an end to drug price gouging, requiring that prescription drugs prices be affordable.
  • Insist on getting value for our health care dollar with common sense measures that pay hospitals and doctors for the quality of the care they provide rather than the amount they provide.
  • Provide incentives to coordinate our care, keep us healthy, help us take care of our own health, and improve the health of our communities.
  • Ensure that all of us, regardless of our gender, race or ethnicity, get access to quality care, investing in research and services that take account of our differences, our communities, and our cultures.

As with most change in our nation’s history, states are pioneering these innovations, from covering immigrants in California, to integrated delivery systems for Medicaid in Oregon, to community health delivery for people with chronic diseases in Vermont, to setting global budgets for health care spending in Maryland. Advocates and organizers who have spent years championing health care for all are now working to shape delivery system reforms around progressive goals.

These proposals are bold—even audacious—but they are achievable over time because they meet an essential prerequisite for any health care reform in the United States: They build on the health care system we have today. And even if we get Sanders’s political revolution, they will still be essential to create a health care system in the United States that provides good health care and promotes good health for all of us.