Discussion of Commonwealth Fund Recommendations for Improvements in the US Health System
1) Cover the remaining 26 million uninsured
2) Strengthen and better organize the delivery of Primary Care
3) Reduce financial barriers and change the patient financial incentives
4) Build on the successes of pay for performance
5) Get the hedge funds out of health care
6) Reduce the administrative inefficiencies
7) Build a strong public health system
8) Reduce the gun violence and drug abuse epidemics
Covering the remaining 26 million uninsured
There are three primary remaining groups of uninsured: the Medicaid eligible in the ten states who have declined the Medicaid expansion, immigrants, and those eligible for but reluctant to enroll in coverage or unaware of the programs. Sixty percent of the remaining uninsured are eligible for the Medicaid expansion or the Exchanges but not enrolled. https://www.kff.org/uninsured/issue-brief/a-closer-look-at-the-remaining-uninsured-population-eligible-for-medicaid-and-chip/
Massachusetts, the pioneer on whose programs the ACA was modeled, has now achieved a 2.5% uninsured rate while Texas is the worst in the nation; it has about 17% uninsured. Ten, primarily Southern, states have chosen not to take the Medicaid expansion. They account for 6% of the remaining uninsured. The federal government offers a 90/10 match to these states to cover their uninsured poor. Texas, for example, has a Medicaid eligibility level for parents of about 15% of FPL, and it excludes all other adults without dependent children living at home. The Medicaid expansion offers coverage for all US citizens with incomes less than 133% of FPL (about $20,000 for an individual and $41,500 for a family of four). https://www.kff.org/medicaid/issue-brief/how-many-uninsured-are-in-the-coverage-gap-and-how-many-could-be-eligible-if-all-states-adopted-the-medicaid-expansion/#:~:text=Ten%20years%20after%20the%20implementation,states%20adopted%20the%20Medicaid%20expansion. It is as yet unclear what President-elect Trump intends to do with the Medicaid expansion and the Biden improvements in affordable coverage in the Exchanges, which I discussed in an earlier blog post.
Immigrants account for about 15% of the remaining uninsured. https://www.kff.org/uninsured/issue-brief/a-closer-look-at-the-remaining-uninsured-population-eligible-for-medicaid-and-chip/ About half of undocumented immigrants are uninsured, and about 20% of legal immigrants are uninsured. The undocumented cannot work legally under federal law; however, they do work for low wages, often in the shadow economy such as day laborers, and/or in industries or positions with low rates of health coverage for their employees like agriculture and construction.
Federal law denies federal financial participation for coverage to the undocumented in full scope Medicaid or in the Exchanges. https://www.cbpp.org/blog/immigration-related-barriers-result-in-high-uninsured-rates-within-all-racial-and-ethnic New legal immigrants (first five years) are also excluded by federal law.
A number of states have now adopted state policies with state only funding (no federal match) to cover some new legal permanent residents and some undocumented workers. https://www.cbpp.org/research/immigration/states-are-providing-affordable-health-coverage-to-people-barred-from-certain California for example covers the low income undocumented and new legal permanent residents through MediCal (Medicaid) with state funds. Colorado and Washington state have used §1332 waivers, and they now cover the moderate income undocumented in their Exchanges (Covered California in our state). These pioneering states need all of our support.
President-elect Trump’s stated approach is to round them up and deport them to their countries of origin, using the US military. We will soon see how his cruel massive deportation plan works out.
The remaining uninsured (60%) who are eligible but not enrolled are people who cannot afford the premiums in the Exchanges, or people who do not know about the programs, or people who do not want coverage until they get sick and need it urgently. Some states do a great job of explaining and enrolling. In his first term, Trump cut all the federal outreach and navigator funding; Biden then restored it. Providers have strong incentives to help their uninsured patients learn about and enroll in coverage, where it is available. However many of the uninsured lack a regular provider to assist them.
Strengthen and better organize the delivery of Primary Care
The Commonwealth Fund is suggesting a well-organized primary care delivery system like the Netherlands. However, we do not have nearly enough primary care doctors – about 30% of American doctors practice primary care, as compared to the recommended 40%. This leads to serious primary care shortages in many rural and inner-city communities. It will take a sustained commitment of the medical schools and the medical community to remedy the national shortage.
There are some exemplary models of well-coordinated and integrated primary care in the US that should be more widely dispersed and emulated. https://www.ncbi.nlm.nih.gov/books/NBK571813/
Commonwealth recommends that the practice of hedge funds and other entities buying up primary care practices be banned because it is increasing the prices of already exceedingly high priced American medical care and not improving the quality of patient care at all, in fact it has been harming it. https://www.statnews.com/2024/08/19/private-equity-health-cares-vampire/ and https://academic.oup.com/healthaffairsscholar/article/2/4/qxae047/7643246
Reduce financial barriers and change the patient financial incentives
Commonwealth Fund references and recommends the German and Dutch insurance system models on this issue. Germany limits patient out of pocket to 2% of income and for the chronically ill to 1% of income. Netherlands exempts primary care, maternity care and child care from cost sharing requirements. In both countries, primary care doctors are organized to provide after hours care.
The US ranks dead last by a large margin in accessibility and affordability of health care for Americans. https://www.commonwealthfund.org/publications/fund-reports/2024/sep/mirror-mirror-2024 Our copayments and deductibles are for the most part not linked to incomes, nor are our premiums, and they serve as major barriers to needed care and coverage for too many Americans for whom they are unaffordable, creating a highly inequitable system.
US efforts to expand primary care access in poorly served rural and inner-city communities have been limited to the development of community and rural health clinics; we also need more private doctors and more hospitals practicing in our health care deserts, and there is insufficient federal help to do so. Rural hospitals and vital health services are being closed due to the difficult economics of delivering care in sparsely populated and poorer communities. Particular hospitals, insurers, and health delivery systems exclude or limit lower income patients and their sources of coverage and favor those with the most lucrative payment structures. Some doctors have developed “concierge” care, catering to the wealthiest while excluding the rest. These practices ought to be publicized, shamed, and otherwise discouraged.
Medicaid has been expanding and remains a source of vital coverage with no or nominal cost sharing for many, but not all of the nation’s poor, and for low-income seniors and the disabled (the Medi-Medis). But Medicare itself for our nation’s seniors is rife with outdated copays, co-insurance, deductibles, premiums, and exclusions of vital services ranging from dental and vision care to long term care; the program needs to be updated; seniors are voting with their feet and choosing Medicare Advantage Plans (Medicare Part C). In almost all private insurance offered through employers, cost sharing and premiums are standard for all the employees from the lowest paid to the highest paid, rather than being linked to incomes or wages, and thus made more affordable for the low wage workforce.
The Affordable Care Act made a start in several important ways: 1) the Marketplaces linked premium assistance and cost sharing reductions to an individual’s or family’s income, 2) there are now limits on the amount of patient cost sharing, and 3) there is a basic minimum package of services with no copays for essential preventive care. Insurers can no longer exclude customers or services based on a patient’s pre-existing condition or genetic profile. The Biden Administration made important affordability improvements in the premium assistance component of Exchange coverage, and people have responded by enrolling in record numbers.
The next administration that is truly committed to improving the nation’s health should link cost sharing and premiums to individual and family incomes. It needs to remove the bad actors (for profit vultures and others) from their government contracts (Medicare, Medicaid and the Exchanges), and it should require all contractors and certified providers with federal programs to assure equitable availability of and access to services for all their patients. It is time to put a stop to the cherry picking of patients for profit.
Build on the successes of pay for performance and value-based reimbursements
The US payment system was reformed to focus on prevention and patient safety, and the performance of the US health system responded quite dramatically to the changed incentives, so that on Commonwealth’s “care process” measurement the US system now ranks second. These building blocks have the potential to be used to improve patient outcomes and life expectancy, where the US is a notable laggard dangerous to the entire American society.
One serious problem impacting patients’ long-term outcomes is the lack of continuity of care and coverage in our system. Too many Americans experience being churned from one program to the next, one insurer to the next, and one doctor to the next without continuity of care, treatment, and the consistent doctor patient relationships that are essential to improving patients’ long term outcomes.
Getting the hedge funds out of health care
The hedge funds and others are buying up the health care providers. They are raising prices, closing facilities, reducing competition, and in some instances reducing the quality of care. https://nihcm.org/publications/the-growth-of-private-equity-in-us-health-care-impact-and-outlook and https://www.milbank.org/quarterly/opinions/private-equity-impacts-on-health-care-federal-and-state-legislative-and-regulatory-actions-will-it-matter/
See the industries’ countervailing perspective at https://www.privateequityinternational.com/private-equity-and-healthcare-a-bitter-pill-to-swallow/ The article written from the industries’ perspective emphasized the need to quickly get the bad actors out of the business, and have clear, transparent information on the system improvements being financed through private equity investments.
Reduce the administrative inefficiencies
The US and Switzerland ranked worst; they each had multiple insurance companies that posed administrative obstacles to getting paid for their patients and providers alike. On the other hand, in Australia, which is a hybrid model of public and private insurance, the providers bill the payers electronically and are promptly reimbursed electronically.
Build a strong public health system
Commonwealth recommends we build a strong, respected, scientifically grounded, and effective public health system at all levels of government. The Covid epidemic woke all Americans to the importance of public health and highlighted its poor performance in keeping us all as safe as possible from a highly infectious and lethal new disease. Its poor performance was exacerbated by politicians who gave fatal misinformation about the disease and the necessary safeguards and treatments. Many Americans died unnecessarily because of the spread of misinformation and disinformation. Many children lost valuable school learning time due to misinformation and poor policy formation.
Increase life expectancy, reduce preventable deaths, reduce the gun violence and drug abuse epidemics
We are dying on average 4 years earlier than our counterparts in the other developed nations studied by Commonwealth, and we have a far higher rate of preventable deaths due to the poor functioning of the US health system. Our poorly performing health system is compounded by our absurdly high rate of gun violence and deaths and by the devastating plagues of the substance abuse epidemics. These are in turn compounded by our history of racial oppression, our weak social safety net, and our rising income inequality. That is a lot to take on for our society and political system after an election which has empowered those who seem inclined to worsen each of these elements. We are going to have to build the necessary reforms from the bottom up, from local governments, from state governments, from the private sector, with the realistic expectation of little to no practical assistance and lots of resistance from the soon to be new leaders and policy makers in the federal government.