The Next Big Thing in Health Reform: Where to Start?

The next Democratic candidate for president or Democratic Congress will likely embrace some sort of public plan as part of the “next big thing” in health reform. Numerous congressional Democrats have thrown their weight behind Senator Bernie Sanders’s “Medicare for All” bill. Support is also growing for various kinds of “public options”—opportunities to expand the role of public programs through Medicare, Medicaid, or the health insurance marketplaces.

These ideas are similar in their goal of providing lower-cost, simpler, and more secure health-care coverage for all Americans through insurance plans that are publicly backed and organized. The proposals reflect frustration with private insurers and a belief in a stronger and more direct role for government, but they differ in how they work. Single-payer plans concentrate health-care finance in the federal government, while Medicare and Medicaid buy-in proposals build on existing programs, payment rates, and relationships with health-care providers.

The proposals also differ in where they start. Barack Obama is among the many who have said that if we could start from scratch, a single-payer system would make the most sense. The U.S. health system, however, is far from a blank slate. It is the largest in the world in spending. Relatedly, it is one of the nation’s largest employers, as well as its most lucrative: Nine of the top ten highest-paid occupations are in health care, and both the industry and its employees are likely to resist changes they see as threatening. More than nine in ten Americans now have coverage thanks to the Affordable Care Act (ACA). Changing this entrenched system incrementally has proved daunting; changing it radically may prove impossible. The cliché “don’t bet against the house” is safely applied in health policy.

In light of those considerations, we focus here on four major approaches to expanding the public role in achieving the goals of health-care reform. These approaches do not necessitate picking one preferred plan over all others, nor do any of them inevitably lead to a predetermined outcome. The expansion of programs often stalls, as is evident in the long lags between past health reforms. Consequently, the next steps we take are as important as the ultimate destinations that we hope to reach.

– American Prospect

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