Will a new President make health insurance fairer?

US bas­ket­ball super­star Michael Jor­dan recent­ly opened a sec­ond med­ical clin­ic. Locat­ed in a poor part of Char­lotte, North Car­oli­na, the clin­ic aims to pro­vide pri­ma­ry and pre­ven­ta­tive care for those with lit­tle or no health insur­ance. Jor­dan, who worked with inte­grat­ed health­care provider Novant Health to open the clin­ic, per­son­al­ly donat­ed $7 mil­lion towards the project. 

“The impact of the first clin­ic has been mea­sur­able and if COVID-19 has taught us any­thing, it is the impor­tance of hav­ing acces­si­ble, safe and qual­i­ty care in com­mu­ni­ties that need it most,” accord­ing to Novant Health’s chief exec­u­tive Carl Arma­to. 

Inte­grat­ed health­care mod­els, such as those pro­vid­ed by Novant, are becom­ing more com­mon in Amer­i­ca amid mas­sive indus­try con­sol­i­da­tion. But they’re just one poten­tial fix to a sys­tem plagued by esca­lat­ing costs and an unin­sured or under­in­sured pop­u­la­tion. In the case of Michael Jor­dan’s clin­ics, Novant pro­vides free or reduced care to patients with house­hold income up to 300 per cent of the fed­er­al pover­ty lev­el of $26,200 for a fam­i­ly of four. 

The question of health insurance is political

In past decades, numer­ous pres­i­dents, includ­ing Roo­sevelt, Tru­man, Nixon, Carter and Oba­ma, have tried to reform health insur­ance in Amer­i­ca. Only Pres­i­dent Barack Oba­ma, with the Afford­able Care Act (ACA), man­aged to pass leg­is­la­tion to reform insur­ance and make health­care more acces­si­ble. How­ev­er, it has come under attack by Repub­li­cans and is cur­rent­ly being debat­ed in the Supreme Court for being uncon­sti­tu­tion­al. 

With Demo­c­rat Joe Biden as the pres­i­dent-elect, it is like­ly that many of the things Pres­i­dent Don­ald Trump did to weak­en the ACA will be reversed. But beyond that, sweep­ing change is unlike­ly. 

“I’ve been study­ing this for 30 years. And the first ref­er­ence I could find to health­care costs being a huge prob­lem for many hos­pi­tals was in 1961. I’m not say­ing it will nev­er change, but you know, it just goes on,” says Pro­fes­sor Sher­ry Glied, dean of New York Uni­ver­si­ty’s Robert F. Wag­n­er Grad­u­ate School of Pub­lic Ser­vice. 

One of the many prob­lems with Amer­i­ca’s com­pli­cat­ed patch­work of health­care and insur­ance sys­tems is there are few ways to con­trol costs. US drug prices have risen 33 per cent since 2014, accord­ing to research by GoodRx, an online plat­form that helps Amer­i­cans find the low­est prices of pre­scrip­tion med­ica­tion. In addi­tion, the cost of all med­ical ser­vices com­bined have increased 17 per cent since 2014, the com­pa­ny found. Mean­while, the num­ber of unin­sured peo­ple increased in 2019, the third year in a row, accord­ing to data from the Kaiser Fam­i­ly Foun­da­tion.

Are integrated systems the secret to affordable care?

Near­ly half of health insur­ance in Amer­i­ca is pro­vid­ed through an employ­er. These plans are expen­sive. Annu­al fam­i­ly pre­mi­ums for employ­er-spon­sored health insur­ance was $21,342 in 2020. Since 2010, aver­age pre­mi­ums have increased 55 per cent. Not only that, but about 83 per cent of these plans have an aver­age deductible of $1,655. 

Indus­try experts hope more inte­grat­ed sys­tems, which bind togeth­er insur­ance, hos­pi­tals and provider clin­ics into one, may help put pres­sure on costs. In recent years, there’s been a wave of ver­ti­cal inte­gra­tions with health plans buy­ing phar­ma­cy ben­e­fit man­agers or pri­ma­ry care physi­cian groups or a hos­pi­tal sys­tem buy­ing oncol­o­gy clin­ics. 

This trend is rel­a­tive­ly new and it will take a long time to mash some of these giant com­pa­nies or sys­tems togeth­er. But it’s been encour­aged on the hope inte­gra­tion could lead to bet­ter co-ordi­na­tion across the var­i­ous parts of the patien­t’s health­care jour­ney, dri­ve down costs and improve health out­comes, says Chris Sloan, asso­ciate prin­ci­pal at Avalere Health, a health­care con­sult­ing firm.

“In the­o­ry, you can align the incen­tives to reduce costs and dri­ve towards bet­ter health out­comes, rather than just get­ting paid on a fee per ser­vice basis,” he says.  

Could the President-elect turn healthcare on its head?

In the last four years, the Trump admin­is­tra­tion has sought to elim­i­nate or weak­en the ACA by cut­ting mar­ket­place sub­si­dies and allow­ing “junk health plans” that steer young, healthy peo­ple into cheap, short-term poli­cies, which con­se­quent­ly rais­es costs for every­one else. Many of these actions did not need to go through the leg­is­la­ture, which means every­thing they did can be reversed, says Glied.  

Indus­try experts expect Biden, along with a Demo­c­rat-con­trolled Con­gress, to undo or tight­en up some of the loos­ened restric­tions Trump put in place. Biden could bulk up sub­si­dies for low-income indi­vid­u­als who oth­er­wise could not afford health insur­ance. He could also strength­en pro­tec­tions for peo­ple with pre-exist­ing con­di­tions by lim­it­ing out-of-pock­et costs. 

Among the president-elect’s more con­tro­ver­sial pro­pos­als is a pub­lic insur­ance option. One poten­tial upside is a pub­lic plan would pre­sum­ably pay prices sim­i­lar to those Medicare pays. 

“The idea would be to cre­ate com­pet­i­tive pres­sure for pri­vate insur­ance to work a lit­tle hard­er and nego­ti­ate some bet­ter dis­counts with doc­tors and hos­pi­tals, and phar­ma­ceu­ti­cal com­pa­nies,” says Karen Pol­litz, senior fel­low at the Kaiser Fam­i­ly Foun­da­tion. How­ev­er, the like­li­hood of such a pro­pos­al pass­ing with a Repub­li­can-dom­i­nat­ed Sen­ate in place is extreme­ly unlike­ly, says Avalere’s Sloan. 

The most like­ly out­come in the next four years is noth­ing changes

Mean­while, some sur­veys show that dis­sat­is­fac­tion with high health­care costs is grow­ing. Accord­ing to a Gallup poll from Decem­ber 2019, 63 per cent of Amer­i­cans say the coun­try’s health­care sys­tem is in “a state of cri­sis” or has “major prob­lems”.

Yet sup­port for a gov­ern­ment-run pro­gramme remains mixed. The major­i­ty of Amer­i­cans believe the gov­ern­ment should be respon­si­ble for ensur­ing every­one has insur­ance, but most also reject the idea of a gov­ern­ment-run health­care sys­tem.    These mixed feel­ings are play­ing out in pol­i­tics. ACA was “a pret­ty tar­get­ed” bill when it passed in 2010, says Sloan, not­ing it most­ly tar­get­ed the indi­vid­ual mar­ket. Even so, the move “dom­i­nat­ed the polit­i­cal dis­cus­sion for the next six years with vot­ers fight­ing to repeal it or keep it or sup­port it or bring it down”, he says. “The most like­ly out­come in the next four years is noth­ing changes.”

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