How much healthcare should we have

The opportunity for health plans to improve quality and reduce costs by embracing primary care medical homes. Accessed July 3, Kacik, A. Monopolized healthcare market reduces quality, increases costs. Himmelstein, D.

A comparison of hospital administrative costs in eight nations: U. Patient-Centered Primary Care Collaborative. Results and evidence. Read More. Goal To ensure health care coverage for everyone in the United States through a foundation of comprehensive and longitudinal primary care. Introduction The health care system in the United States is uncoordinated and fragmented and emphasizes intervention rather than prevention and comprehensive health management. Key Elements of the Framework Everyone will have affordable health care coverage providing equal access to age-appropriate and evidence-based health care services.

Everyone will have a primary care physician and a medical home. Insurance reforms that have established consumer protections and nondiscriminatory policies will remain and will be required of any proposal or option being considered to achieve health care coverage for all. Any proposal will reflect at least a doubling of the percentage of health care spending invested in primary care. Additionally, U. A defined set of visits and services to a primary care physician will not be subject to cost-sharing.

In any system of universal coverage, the ability of patients and physicians to voluntarily enter into direct contracts for a defined or negotiated set of services e. Additionally, individuals will always be allowed to purchase additional or supplemental private health insurance.

To achieve health care coverage for all, the AAFP supports bipartisan solutions that follow the above referenced principles, are supported by a majority of the American people, and involve one or more of the following approaches, with the understanding that each of these have their strengths and challenges: A pluralistic health care system approach to the financing, organization, and delivery of health care is designed to achieve affordable health care coverage that involves competition based on quality, cost, and service.

Such an approach involves multiple for-profit and not-for-profit private organizations and government entities in providing health insurance coverage. Such an approach to universal health insurance coverage must include a guarantee that all individuals will have access to affordable health care coverage. A Bismarck model approach is a form of statutory health insurance involving multiple nonprofit payers that are required to cover a government-defined benefits package and to cover all legal residents.

Physicians and other clinicians operate independently in a mix of public and private arrangements. A single-payer model approach that is clearly defined in its organization, financing, and model of delivery of health care services would be publicly financed and publicly or privately administered, with the government collecting and providing the funding to pay for health care provided by physicians and other clinicians who work independently or in private health systems.

A public option approach that is a publicly administered plan directly competing for customers with private insurance plans could be national or regional in scope. Physicians and other clinicians would continue to operate independently. In such a scenario, there must be at least Medicaid-to-Medicare payment parity for the services provided to the patients of primary care physicians. The key functions of a primary care medical home are: Access and Continuity Planned Care and Population Health Care Management Patient and Caregiver Engagement Comprehensiveness and Coordination Benefits All proposals or options to provide health care coverage for all will be required to cover a defined set of essential health benefits.

A focus on reducing preventable diseases likely would reduce or, at minimum defer, future high-cost spending for preventable diseases. In addition, there should be an increased focus on identifying societal and environmental factors that contribute to increased health care spending. Transparency — an increased investment in primary care and the medical home allows health plans to not only reduce the costs of treating high-risk patients but improve the quality of health services.

Such transparency likely will contribute to reducing excessively high health care costs by informing the public about their costs of care and creating more competition in the health care industry. Consolidation — consolidation in the health system is cause for concern when it comes to affordability. Although consolidations between health systems may allow for reductions in internal costs, such as operating expenses, they create a less competitive market which leads to higher health care costs and insurance premiums.

Such payment policies contribute to excessive spending in our current system. In addition, such payment policies incentivize consolidation, decrease competition between providers of care, and facilitate over-utilization of high-cost health care services. This issue could be addressed effectively through site-neutral payment policies and the elimination of some facility fees. Administrative Costs — a share of the overall costs of health care in United States health care is due to high administrative costs.

Much of these high administrative costs is due to complexities in billing which is exasperated by multiple payers. Countries with lump-sum budgets and fewer health care payers have seen lower costs in administrative spending.

Additionally, no link has been found between higher administrative costs and higher quality care. These advances have extended life expectancy for millions of people, especially those with chronic diseases and some cancers. These advances should be celebrated for the positive impact they have had on millions of people.

However, the escalating costs of pharmaceuticals and biologics places these interventions and treatments out of reach for far too many people. Policies should be established that allow purchasers of health care, including Medicare, to negotiate the costs of prescription drugs. Additionally, there should be greater flexibility in the design of formularies that allow for increased use of generic and bio-similar products.

Figure 1. Summary This framework offers important policy options for the AAFP to move the United States toward a primary care-based health care system in which all people have appropriate and affordable health care coverage, are provided a medical home, and have primary care-oriented benefits. Prices are also set for particular services, like after-hours primary care.

Insurers do have some limited flexibility in which providers they contract with, but the government sets their health care budget for them. We have experimented with that kind of system in the US, as Tara Golshan covered in this series in her story on Maryland. She documented how the state has tried to use a model like this, global budgets, to improve care for patients by encouraging hospitals to focus on the health of their patients instead of whether they have enough people in their beds.

But Maryland remains an exception. And as the research shows, the US spends dramatically more for many common medical services compared to other developed countries:. For most developed economies, their aging populations will present a serious challenge of both cost and care delivery.

The chart below shows what countries were already paying notice the US lags significantly both overall and in public investment and then projects what they will be paying in Yi Li Jie, a spinal atrophy patient I met, has to pay out of pocket for her caregivers; she also has to pay a substantial share of her transportation costs to get to medical appointments.

On the other end of the spectrum, the Netherlands has a universal public program to cover long-term care, even though it has private medical insurance. Of course, the needs for these populations extend beyond the basic provision of medical care. No matter the health system, the most complex patients are going to have the most challenging needs to meet. Nobody has figured out a silver bullet for fixing that yet. It would be the most equitable and the most efficient.

But other countries, like Australia and the Netherlands, have found a significant role for private insurance even as they strive toward the same goal. Frankly, however, private insurance seems to be more of a political compromise and, by extension, to reflect some differences in societal values than a preferred policy solution.

Australia had had private insurance for decades before its universal public insurance plan was introduced in the s; both of its major political parties have come to accept the existence of that program. Private insurance in Australia has given the better-off more options in their health care; that comes at the expense of some equity, but it is a compromise the country has been willing to make as it tries to balance access and choice.

Because a center-right government was in charge, they wanted to pursue a market-driven, managed-competition model to try to fix it. Universal coverage was still a shared goal for all the political parties, but they pursued private insurance to do it because it aligned more with the ideology of the ruling government.

Now critics say that was a mistake, that it has made health care more expensive in the Netherlands. But it was the pragmatic path available to the country at that moment. He had approval ratings for the single-payer plan on big whiteboards, and he had just been showing us the enormous spike in approval among the public for the national insurance plan and its steadiness over the years.

As recently as , 39 percent of physicians said they were either dissatisfied or very dissatisfied with national health insurance. Another 31 percent said they were neutral. Just 30 percent said they were satisfied or very satisfied a paltry 2. I encountered that ambivalence from the two doctors I met in a coffee shop in downtown Taipei. But such complaints are not unique to Taiwan or its single-payer system. The data suggests physicians the world over are often frustrated by their health systems.

Even in countries like the Netherlands and Australia, which have more of a role for private insurance and therefore for doctors to have more choice in their practice and the opportunity to make more money, opinions are split. But at the same time, providers everywhere are generally happy about the actual practice of medicine. All of these systems, even with their varying approaches to insuring people, have had to add other reforms to improve medical care itself.

In Taiwan, that meant setting up a rural health program that employed doctors to work in clinics at mountain outposts and make visits to indigenous communities part of their daily routine. In the Netherlands, it was the doctors who saw a delivery problem and came up with a way to fix it.

Years ago, every individual doctor was responsible for providing after-hours care to their patients if needed. So the doctors proposed a new model: What if they formed cooperatives so they could share the load? They would pool their patients together and each doctor would take a few shifts a month, either providing care in an after-hours clinic or doing home visits. They get paid a flat hourly rate by the private insurance plans.

The result? Today, people in the Netherlands say they have very little trouble getting after-hours care. She has evaluated health care systems on how well they prevent deaths that should be avoidable with accessible medical care.

I had asked her what I thought was a pretty basic question: How would you describe the US health system in relation to other countries? Bottom line: Some plans from the Democrats would cover all Americans — while others would provide insurance to more but leave some number of people uninsured. In a way, this is the fundamental question. The whole reason Democrats are ready to take up health care reform again so soon after the ACA is to fix this problem.

Medicare-for-all Senate and House : Every single American would be covered by a government insurance plan, after a short phase-in period. Medicare for America DeLauro and Schakowsky : This health care plan, informed by the work of the Center for American Progress and Yale professor Jacob Hacker, would achieve universal coverage for all legal residents, through a combination of private and public insurance — at least for the next few decades. It eventually foresees getting to a very similar level of coverage as the Medicare-for-all proposals in Congress, by enrolling all newborns into a government health plan and taking steps that would diminish the role of employer-sponsored coverage.

They would still, after all, be optional programs. A big part of the remaining uninsured would be undocumented immigrants. Bottom line: Democrats are split over whether expanded Medicare should make space for employer-sponsored plans — or get rid of them completely. Currently, the American health care system provides employers with a big incentive to provide coverage: Those benefits are completely tax-free.

This, however, creates an uneven playing field. Medicare-for-all Senate and House : Both the Medicare-for-all plans would make the biggest change and eliminate employer-sponsored coverage completely. Under these options, all Americans who currently get insurance at work would transition to one big government health care plan.

Medicare for America: This plan does let employers continue to offer coverage to their workers so long as it meets certain federal standards. At the same time, it would give employers an alluring, simpler option: stop offering coverage and instead pay a payroll tax roughly equivalent to what they currently spend on health coverage.

As to how alluring that plan would be, that depends a lot on how generous Americans consider this new Medicare program to be. The great unknown is how quickly those benefits pull people away from their work-based coverage into the new Medicare program. Medicare for America makes another policy decision that would erode employer-sponsored coverage: It automatically enrolls all newborns into the public program.

The question of work-based insurance is prickliest for the buy-in plans. Broadly speaking, under those bills, more Americans would be allowed to purchase a public insurance plan under the Medicare umbrella. Everybody who currently buys insurance on the individual market would be allowed to buy a Medicare plan, under each of the buy-in bills. But they differ in important ways in how much they would let people leave their current job-based insurance for the new government plan.

The bill does include a provision, however, allowing workers to keep the government plan once they sign up, even after they leave their current job. We asked Merkley why they left the decision up to the employers, not the employees. Lastly, he emphasized the workers who transition to new jobs or go for a period without coverage would have a chance to sign up for Medicare and then keep that plan even after they get a new job. Workers at larger firms would be frozen out, however.

Medicare X Bennet, Kaine and Higgins : Likewise, small employers eligible for ACA coverage could buy into Medicare under this legislation, but large employers could not.

Medicare-at Stabenow : Any American 50 years old or older would be permitted to buy into Medicare, including those who currently receive health insurance through their job. Healthy America Urban Institute : The Urban Institute explicitly designed its Healthy America plan with the goal of disrupting the large employer market as little as possible.

Those markets would combine 70 or so million people on Medicaid with the people currently covered by Obamacare but more or less leave people who get insurance through their jobs alone.

Bottom line: The vast majority of proposals expand Medicare, the plan that covers Americans over But there is one option that would expand Medicaid, the plan that covers low-income Americans — and another option that creates a new government program entirely.

The American government already finances two major health coverage plans: Medicare and Medicaid. Taken together, these two programs cover one-third of all Americans: 19 percent of Americans get their coverage from Medicare, and 14 percent from Medicaid.

Voters have recently given a boost to Medicaid, too: Voters in Idaho, Nebraska, and Utah all passed ballot initiatives that will expand the program in their states to thousands of low-income Americans. But there are differences in which programs they pick, and one plan that starts a new government program entirely.

Medicare-for-all, Medicare buy-in, Medicare for America: As their names imply, all these plans use Medicare as the base program for expanding health insurance coverage.

Medicare is, after all, the only major health program run exclusively by the federal government Medicaid is run jointly with the states , which can make it an appealing choice for a national coverage expansion.

Traditionally, Democrats have focused on Medicare as a base for expanding coverage. And five of the six legislative proposals we looked at use the program that covers the elderly as the one that would absorb additional enrollees. Medicaid buy-in Senate and House bills : Recently, Democrats have begun to eye Medicaid as another option, suggesting that we should focus on expanding the health plan that covers the poor to Americans with higher incomes.

Brian Schatz D-HI , for example, has offered a bill that would allow every state to let residents buy into Medicaid. A companion bill is offered by Rep. With the expansion of Medicaid under Obamacare, more than a dozen Republican-controlled states refused to extend the program to thousands of their poorest residents.

But some Republican-led states have come around on Medicaid expansion. In an interview with Vox, Schatz said he likes the idea of a Medicaid buy-in because the program has proved popular across the political spectrum.

Obamacare and Medicaid would effectively be combined into a brand new insurance market covering upward of million people, and there would be a public insurance plan under the Healthy America brand. Bottom line: Democrats generally agree that health insurance should cover a wide array of benefits, although there is some variation around how different plans cover long-term care, dental, vision, and abortion.

Every country with a national health care system has to decide what type of medical services it will pay for.