Last week, long-term attempts to repeal the Affordable Care Act, enacted under the Obama Administration, failed. House Republican leaders, facing opposition from Republicans and Democrats, pulled legislation to replace the Affordable Care Act with the American Health Care Act. If successful, the repeal and replacement would have left an estimated 24 million people without health insurance coverage within a decade. The replacement bill would have also reduced access to Medicaid, increased premium costs for many Americans in upcoming years, and restricted access to some women’s health services.
Most Americans opposed the replacement bill.
Like many Americans, I was relieved the new bill didn’t replace the Affordable Care Act – especially for patients desperate for health services. In the course of my medical career, I’ve had the privilege of providing health care for people across the sociopolitical and economic spectrum. I’ve learned that despite our differences, we’re all vulnerable – susceptible to disease and disorder. Merely being alive leaves us with wounds and scars. Nonetheless, due to many factors outside our control – including economic and health care policies – some are more vulnerable than others. These disparities have become clearer and clearer to me over the years as I’ve witnessed many of my patients struggle with working hard for little pay, homelessness, and unimaginably difficult decisions like choosing between food, medications, and heating.
In recent years, with the passage of the Affordable Care Act (sometimes referred to as Obamacare), access to health insurance has expanded, especially for some of the most vulnerable individuals. Before it was implemented, the percentage of people who were uninsured or underinsured was increasing and the pool of doctors to care for them was shrinking. Overall, the Affordable Care Act has increased access to affordable health insurance and preventive and treatment services and helped slow the rate of increase in national health care spending for the first time in years.
While we were moving and between jobs, my husband and I signed up for health insurance through the Affordable Care Act, and it was easy and affordable (more affordable than COBRA). Nonetheless, problems with the Affordable Care Act remain and there is at least bipartisan agreement that improvements should be made – though there are differences of opinions about what those changes should entail.
At this point, it’s worth considering which principles should guide further health care reform. Based on the evidence and experiences around the globe, here are a few ideas:
1) Policies should reflect key moral values like equity, compassion, and respect for dignity.
Many countries around the world place these values, as well as community and solidarity, at the core of their health care policies.
In practice, this approach takes many forms – from universal coverage to a multi-tiered system with a clear safety net for people who cannot afford health insurance. In remarkably different ways, several capitalist democracies across the globe deliver health care for everyone.
Along these lines, in the United States, some are calling for a “Medicare for All” approach in order to increase access to health care.
Though these approaches all differ in their details, they all put patients ahead of inanimate corporations – from drug companies to hospital conglomerates to insurance firms – by increasing transparency, capping or negotiating lower drug prices, limiting hospital costs, and more.
2) Health care should be evidence-based, high value, and cost-conscious.
Though spending growth has slowed in the U.S. and most other countries in recent years, the country’s health care spending exceeds that of other high-income countries. We spend more public dollars on health care than most other high-income countries – even without a publicly financed universal health system. Much of this can be explained by spending on technologies that aren’t clinically indicated – interventions that don’t necessarily improve quality of life or extend life.
U.S. health care organizations are beginning to move in a better direction – toward more high value, cost-conscious care. The Affordable Care Act has hastened some of these positive changes.
3) We need to invest in prevention.
Many health care costs in the U.S. and across the globe are attributable to chronic diseases such as diabetes and heart disease. These diseases and their complications are expensive to treat, but they are preventable.
On the flipside, prevention – especially primary prevention (preventing illness before it occurs) – is cheaper over the long haul. Prevention also helps us live longer and better. The Affordable Care Act established funds for prevention, though some of those investments – which would have battled smoking, lead poisoning, heart disease, diabetes, stroke, and falls among elderly adults and promoted breastfeeding and immunization programs – have since been repealed.
4) Social and economic policies should prevent – not promote – disease.
Right now, many social and economic policies aren’t aligned with prevention goals. Nutrition policy is but one example. For example, agricultural policies currently provide subsidies for meat and dairy production, which end up as commodities that are high in cholesterol and saturated fat and promote illnesses like heart disease, diabetes, and obesity in children and adults.
In another area of social policy, Housing First and supportive housing policies – which provide housing and health care management to individuals who need it regardless of factors like drug use – help reduce costs associated with mental and medical illness.
Overall, studies show that investing in social services – from basic necessities like adequate nutrition and shelter to education and childcare – can help improve lives and lower the cost of health care.
Almost all of us, at some point in our lives, will need some type of health care. Instead of arguing about whether it is a right or privilege, we should focus on what we need to be healthy – as individuals and as a society. In the process, we might discover how our vulnerability unites rather than divides us.