Health care in the United States is complicated and varies from state to state. At a Radcliffe symposium, health professionals, policy and public health experts, and economists, among others, examined the functions and dysfunctions of the affordable care act and explored other health insurance systems at the state and international levels.
So where are we now with health care? Given the complexity of the system—and the politics surrounding it—the answer is always changing, particularly when you consider the policy differences that exist from state to state. “To understand the dynamics and challenges of the US health system, we have to understand the interplay of history, politics, economics, science, and medicine,” said Radcliffe Institute Dean Lizabeth Cohen in her introductory remarks to “It Depends What State You’re In: Policies and Politics of the US Health Care System.” This fall event brought together an interdisciplinary group of scholars and practitioners to shed light on the sometimes muddy debate swirling around health care.
The Affordable Care Act has been the punching bag of health care reform but somehow survives, said Daniel Carpenter, faculty director of the Institute’s social sciences program and the Allie S. Freed Professor of Government in the Harvard Faculty of Arts and Sciences. “Now we regard it as part of the status quo, albeit an unsettled one,” he said. Signed into law in March 2010, the ACA—“Obamacare”—represents the largest expansion of health insurance in more than 50 years, added Benjamin Sommers, an associate professor of health policy and economics at Harvard’s T.H. Chan School of Public Health. Twenty million Americans have gained access to health insurance thanks to the ACA, whether through state expansion of Medicaid, subsidized access to the health insurance marketplace, or children aged 26 and under staying on parents’ plans. Significantly, Sommers said, 31 states and the District of Columbia elected to expand Medicaid. “In that sense, we have a natural experiment in terms of health outcomes and costs,” he said. “The uneven expansion has also yielded striking disparities, with 3 to 4 million low-income adults in the 19 states that have not expanded Medicaid lacking an affordable option for health insurance. “If you are a single parent in Texas, your income has to be under $6,000 a year, as an approximate, to qualify for Medicaid,” Sommers said, citing just one example. (The cutoff in Massachusetts for a two-person household is just over $49,000.)
Given these discrepancies, how has the ACA as a policy influenced the way citizens participate in our democracy? “It wasn’t clear that the ACA would spark engagement,” said the MIT political scientist Andrea Campbell ’88, RI ’13. “As legislation, it wasn’t all that popular.” She found, in some expansion states, participants in programs such as Kentucky’s Kynect and Tennessee’s TennCare were unaware that those names were simply rebrandings of the states’ Medicaid programs. Their new names removed some stigma from the programs, but fewer people grasped the origin of their benefits. Then came Republican efforts to repeal the ACA. “In threatening repeal, Republicans essentially succeeded in making the invisible visible,” Campbell said. Beneficiaries of the ACA—including those with disabled children or with family members suffering from opioid addiction— pushed back the repeal effort.
“Medicaid is the most important health insurance plan in our country today,” said Boston Medical Center President and CEO Kate Walsh, who noted that 39 percent of children, 17 percent of women, and 13 percent of men in the United States receive health care coverage under the plan. In Massachusetts, 1.8 million are covered by MassHealth (the state’s name for Medicaid), at a cost of 40 percent of the state budget; 79 percent of Boston Medical’s revenues come from government sources. “We have to figure out collectively how to reduce the spending and keep people well,” Walsh said. “The key is going to be a rigorous focus on the social determinants of health.” Fifteen years ago, staffers at Boston Medical realized that one-third of its patients suffered from food insecurity, so they created an on-site food pantry with prescriptions available for a three-day emergency supply of food. They began by serving 500 people a month, Walsh said. That number has since increased to 7,000. Last summer, the hospital began farming the rooftop of its power plant, producing approximately 15,000 pounds of fresh vegetables in one season.
“Health is much more than health care,” said Georges Benjamin, executive director of the American Public Health Association. “Those are the social determinants we always talk about. . . . Your zip code fundamentally determines your access to a whole range of things.”
Ultimately, universal coverage should be the national policy, he said. But how to mobilize the political energy necessary for change? The answer, Benjamin said, lies in getting people to grasp the significance of a public health service—clean water, for example. Until it’s gone (think Flint, Michigan), that can be a difficult thing to communicate. “The business community gets it,” said Benjamin, noting that companies use metrics such as the percentage of obesity and other indicators of a community’s health when deciding where to locate a new factory.
Moving on from the ACA, the Harvard Medical School assistant professor Zirui Song moderated a second panel, which examined the potential of alternative health care models. In California, for example, a state legislative measure known as the Healthy California Act aims to institute a single-payer approach. Michael Lighty, director of public policy for the California Nurses Association and National Nurses United, cowrote the bill. “We’re on the side of guaranteed health care,” said Lighty. “We see it as a moral imperative.” Analysis shows that the plan would cost $331 billion and save $375 billion, ultimately reducing the state’s spending on health care by 18 percent. “Seventy percent of health care expenses in California are publicly financed,” Lighty said. “We are simply not getting our money’s worth. This is essentially a system that uses tax money to subsidize an industry model of revenue and profit instead of guaranteeing health care for all. That’s what we’re changing.”
William Hsiao, a professor of economics at the T.H. Chan School of Public Health, designed a single-payer system for nine countries around the world. The United States, he said, is the only affluent country in the world that has built its health care system on the free-market principle; yet its quality of care is highly uneven, while health care costs continue to escalate. Research shows, Hsiao said, that moving to a single-payer system in the United States would lower spending by nearly $1 trillion annually, through reduced administrative costs ($500 billion), reduced abuse and fraud ($150 to $180 billion), reduced drug costs ($150 billion), and reduced costs for end-of-life care ($80 to $100 million). The expense of making this transition, which would involve expanded and improved coverage for the millions of Americans who need it and retraining for the 2 to 4 million people who would lose their jobs, would total some $400 billion to $500 billion.
“So why aren’t we there?” Hsiao asked. “Here I venture into political economy.” Simply put, the losers in a single-payer scenario—the private insurance industry, medical administrative personnel, and big pharma—are more powerful than the uninsured and underinsured who would benefit.
Michelle McEvoy Doty, vice president of survey research and evaluation for the Commonwealth Fund, broadened the scope of comparison. She said that Australia, the Netherlands, and the United Kingdom are the world’s top performers in health care; all offer some version of universal care, whether through a single provider (the National Health Service in the UK), a single-payer insurance program (also known as Medicare in Australia), or competing private insurers (the Netherlands). Doty recommended three short-term strategies to create greater stability in the US market, including enforcement of the individual mandate; the funding and support of outreach and enrollment efforts; and payments to insurance companies for providing cost-sharing reductions to low-income consumers. Longer-term recommendations included making tax credits and cost-sharing reductions available to those with incomes above the poverty line; Medicaid expansion in the remaining 19 states; a reinsurance program to reduce premiums; and a fallback health-care option for counties without insurance options.
Drilling down to next steps, Song asked the panelists what changes the United States could feasibly make over a 10-year horizon. “I’m the true optimist in the room,” said Lighty, who believes we have “a real shot” at passing the Healthy California Act. “If California looked different from the United States, and more like the Netherlands or Australia, that would motivate the federal government to move to a Medicare-for-all system much more quickly,” he said. “These countries transitioned to [their systems] 40 to 70 years ago, and it took 20 or more years to get to that point,” Doty said. “We have to operate within that political reality when we’re thinking about next steps in the United States.”
Single-payer insurance won’t be discussed in a serious, politically viable way until the 2024 presidential election, Hsiao estimated. Policy making, he said, occurs in three stages. First, a key issue is embraced by a political party or a powerful group. “Senator [Bernie] Sanders got the Democratic Party to do that. That’s a vision, like a beautiful mountaintop.” In the second, a politically viable option is designed. In the third, legislation is created. “That’s where the horse trading and what you call sausage making occurs,” said Hsiao. “Then you come up with something really workable. We are, in my view, at the first stage.”
Any reform will create many small winners but a few very powerful losers, said Janet Rich-Edwards, faculty codirector of the Institute’s science program and an associate professor at Harvard Medical School and the T.H. Chan School of Public Health. For this reason, all citizens need to be aware of what is at stake in health care reform. And we can all be part of the solution: “Different sectors need to come together to solve these problems, to elevate health as a shared value that reflects our commitment as a nation to justice, equality, and democracy,” Rich-Edwards said.
Julia Hanna is an associate editor at the Harvard Business School Bulletin.