More than six months into the Trump presidency, the Republicans have failed to repeal and replace the Affordable Care Act (ACA). While the ACA is flawed, it is hard to comprehend how the final version of the Senate’s failed health-care bill, which the Congressional Budget Office estimated would result in higher premiums and 16 million Americans losing their insurance, would have been an improvement.
No bill can be an improvement on the ACA unless it expands coverage and reduces costs. The idea of establishing a single-payer system has become popular among progressives, garnering the support of 33 percent of Americans this June, according to Pew Research. While not a ludicrous proposal, since countries such as Canada have proven such a system is viable, I agree with economist Paul Krugman that current political realities in this country render the immediate establishment of a single-payer system improbable. As Krugman argued in a Jan. 18, 2016, New York Times article, a single-payer system would result in higher taxes on the middle class and upset millions of Americans who have good insurance.
The introduction of a public option, guaranteeing universal coverage while allowing elements of the private market to remain, seems like an interesting alternative. Under such a system, anyone desiring public health care could obtain it, perhaps paying for it through a payroll tax. Those unable to afford insurance could be covered at the public’s expense, thus covering the 3 million Americans who fall in the Medicaid gap, according to the Kaiser Foundation.
Anyone dissatisfied with public insurance could opt out and get private insurance. The government could thus compete with private insurance companies, driving down costs.
The French health-care system, which the World Health Organization ranked the best in the world in 2001, is an example of such a mixed system. It guarantees all its citizens coverage through the national health system while still permitting the purchase of supplementary private insurance.
In order to expand coverage, we must reduce medical costs, since these expenses would render a public insurance system uneconomical. Perhaps the most profound issue with the ACA was its inability to control rising medical expenses.
According to the Commonwealth Fund, France spent $4,620 per capita on health care in 2014, as opposed to $9,364 in the United States. Government regulation of medical costs has enabled France and several other countries to reduce health-care costs. Price controls, however, generally reduce supply, since reduced profits give producers less incentive to supply their goods. While this model may not pertain to the pharmaceutical industry, where companies like Gilead make astronomical profits — sometimes as high as 50 percent — other options remain for reducing medical costs.
A free market for pharmaceuticals does not exist in America, since the pharmaceutical lobby has managed to restrict pharmaceutical imports from countries with lower drug prices. But allowing more imports from nations that hold their pharmaceutical industry to high standards could increase competition and lower drug prices.
Yet, reducing drug prices will not be enough. In a 2011 Foreign Affairs article titled “How Healthcare Can Save or Sink America,” former Office of Management and Budget director Peter Orszag supported a provider-value approach, under which health-care providers are reimbursed based on the quality rather than the quantity of care provided. Reducing the number of ineffective or unnecessary procedures and holding health-care providers to certain quality standards could substantially reduce costs. Institutions that follow such an approach, such as the Mayo Clinic, demonstrate this.
Expanded coverage means that healthy individuals will have to assume some of the burden of paying for the ill. Many Americans seem to question why any individual should be obligated to ensure the welfare of their fellow citizens. Perhaps the simplest answer is that this attitude is immoral: that it is disgraceful that in the world’s wealthiest nation, having an insufficient income could be tantamount to a death sentence for a chronically ill individual.
The ACA was an advancement for health care, and any future health-care law should continue the trend toward universal coverage. Anything to the contrary would be a regressive and callous act, which could negatively affect millions.
Alexander Diwan is a native of Cranston and a student at Brandeis University.