Health Policy

Physicians Should Lead on Healthcare Reform


(This is the first in a series of excerpts from Terry’s new book, Physician-Led Healthcare Reform: a New Approach to Medicare for All, published by the American Association for Physician Leadership.)

Even before COVID-19, healthcare reform seemed to be stuck between a rock and a hard place, but there is a rational way forward. This approach, which I call “physician-led healthcare reform,” would engage doctors in building a healthcare system that was safe, effective, patient-centered, timely, efficient, and equitable, to use the Institute of Medicine’s set of foundational goals in its landmark book, Crossing the Quality Chasm: a New Health System for the 21st Century.Primary care physicians, rather than hospitals, would be in charge of the system, and they’d work closely with specialists and other healthcare professionals to produce the best patient outcomes at the lowest cost.

It would take a decade or more to restructure the healthcare system so that this goal could be achieved. Similarly, the transition to a single-payer insurance system needs to be accomplished gradually—although the pandemic might accelerate that timetable. Most people are not yet ready to abandon employer-sponsored insurance, and there’s still a lot of distrust of the government. Providers are more likely to accept changes in how they’re paid over time than all of a sudden. Additional benefits can also be brought online slowly. Ideally, we could transform healthcare financing over a 10-year period while rebuilding the care delivery system at the same time.

That is why implementing Medicare for America—a reform plan devised by the Center for American Progress and embodied in a current House bill–makes more sense than going directly to Medicare for All: it changes the system incrementally while achieving universal coverage fairly quickly. Medicare for America would do this by enrolling the uninsured, people who purchase individual insurance, and those now in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). People would also be enrolled automatically at birth. Companies could enroll their employees in Medicare for America, and employees could opt out of employer-sponsored plans and enroll in the public plan.

Gerald Friedman, a University of Massachusetts Amherst economist who crunched the numbers for Bernie Sanders’ 2016 Medicare for All bill, objects to Medicare for America because it includes a major role for private health plans; however, an approach like this could gradually move us away from private insurance and could morph into a single-payer system over time. If so, the taxes required to support the system would have to be raised. Nevertheless, private insurance premiums would go away and insurance costs (or health taxes) for individuals would become income-related, greatly increasing affordability. Whatever gap that left in healthcare financing could be filled by raising taxes on the wealthy and corporations.

The big debate would be over how much to increase benefits. Should they be limited to the “essential” health benefits required of plans on the ACA insurance exchanges? To what extent should vision, hearing, dental, and behavioral healthcare be covered? How much long-term care should the program encompass? Should coverage of long-term care exclude institutions such as nursing homes, as Sanders proposes? Should there be any cost-sharing?

Other countries with national health insurance have faced the same challenges and have found their own solutions. Cost-sharing barely exists in Canada, but 12% of Canadians have private insurance that covers vision and dental care, prescription drugs, rehab services, home care, and private hospital rooms. In the United Kingdom, similarly, about 10% of residents buy private plans that primarily allow them to avoid long waits for elective surgery. In Germany, more than 90% of the population is in the statutory health insurance system (those with higher incomes can opt for expanded private coverage), but personal outlays on drugs, nursing homes, and other items accounted for 13% of health spending in 2014. The French have coinsurance of 20% for inpatient care, 30% for doctor visits, and 30% for dental visits. They also pay out of pocket for dental and vision services.

Cost-sharing and some limitation on benefits could get us on the path to financing the extra costs of national health insurance if we don’t favor large increases in taxes. High out-of-pocket costs or poor benefits, however, would limit access to healthcare.

We don’t have to wait for care delivery reform before implementing universal coverage. To control costs, though, our very inefficient, fragmented system needs major renovation work while we’re in the process of covering everyone. In addition, we must find a way to reduce the costs of drugs and new technologies without stifling innovation. If we do all of this properly, we could have national health insurance within a decade, along with a care delivery system designed to control healthcare costs in a way that patients and providers could accept.

A number of health policy experts have pointed out recently that healthcare providers would be weathering the pandemic far better if they’d moved from fee for service to value-based payments. If they’d been capitated, for example, they would have received guaranteed monthly payments instead of seeing their fee for service income plunge. But unless doctors are willing to take a fair amount of financial risk—which, so far, most of them have been unwilling to do—this vision cannot come true. Whether they will do so in the future depends on how much the pandemic breaks them financially and whether a future government is willing to remove the obstacles in their way.

Ken Terry is a journalist and author who has covered health care for more than 25 years.