Six times in the 20th century, starting with Republican President Theodore Roosevelt, Americans debated legislation that would enact some form of national health insurance. Under presidents ranging from Teddy Roosevelt to Bill Clinton, the nation considered the issue and failed to act. Then, in his first term, with Democratic majorities in both houses of Congress, President Barack Obama was able to pass the Affordable Care Act. In 2015, the U.S. Supreme Court found the ACA to be constitutional.
While there are many complaints about the ACA, the legislation has done something that was needed in the United States: It provided a way for millions of Americans to get health insurance. By and large, these are working Americans employed by companies that could not offer health insurance as part of the wage package. In this last election cycle, the phrase has become "repeal and replace." The assumption is that there ought to be some form of national health insurance. The crucial question now is: Replace it with what?
There are three important topics in health care policy that always intersect: who is covered and how they are covered by insurance, the cost of medical care, and choice about what procedures and care are delivered. You cannot fix one without affecting the other two. So we need to look for a replacement model that will both give people access to health care (ACA) and address the other issues of cost and choice.
The cost of health care is not merely an economic issue; it is also a social and ethical issue. We live in a world of limited resources, and we already spend over $3.8 trillion on health care as a nation. That is roughly $10,000 annually per person. And as we spend more of our resources on health care, we have fewer resources to address other areas of need, such as police protection, education, or good transportation.
While the U.S. outspends every other nation in the world, our health care outcomes are not the best. Comparatively, life expectancy in the U.S. is 42nd in the world. And 60 years after President Kennedy started the President's Council on Physical Fitness, the United States is now the second most obese nation in the world, with 31.8 percent of its population classified as obese.
There are many reasons that the cost of health care has escalated, but, to borrow from Shakespeare, the fault of spending so much on health care lies "not in the stars but in ourselves." Many of the diseases and illnesses that afflict Americans do not simply happen to us. They are self-inflicted. Many of our daily decisions about how we live contribute to illness and sickness. We have come to treat our bodies like cars or appliances. We use them until they break, and then we get them repaired or replaced.
One way to address these three issues simultaneously is to put more control over health care into the hands of patients and put more responsibility on patients. The way we purchase health care is unlike anything else in American life. Someone else -- the HR office of our employers or those who design government programs like Medicare -- make decisions about what is covered (procedures, drugs) in our plans. We don't make those choices, which is unlike many other goods and services that we purchase.
So how can we provide health insurance for everyone, control the cost of health care, and allow individuals greater choice as to what is included in their health care coverage?
One way to do this would be to develop a new model for health insurance that puts individuals in charge of their insurance and incentivizes them to take better care of themselves. Rather than have insurers or the government design health care packages (which procedures are included, which aren't) and systems (which doctors and hospitals are in-network or out-of-network), devise a system of insurance vouchers and let people make their own decisions about what they want covered and by whom.
I would argue that a new model of insurance can accomplish several important goals simultaneously. First, it gets the employer and insurance companies out of the business of deciding what should or should not be included in people's insurance packages. The individual decides what he or she wants done and by whom. Second, it may help to make people (the consumers) more aware of the costs of health care and what they are actually spending. Right now, there is a complete disassociation of patients from the cost of care, in part because physician and hospital bills are unlike any other bills that people receive. When people receiver a bill for purchases, the bill usually represents the unit cost of the product or service. But in health care, the costs are spread over populations of people and are often the product of negotiations between insurers and health care providers; in short, the bills are largely convoluted fiction.
Not all, but much of what happens to us when our health breaks down is self-inflicted. We need a health insurance system that puts more responsibility on patients for their own health and their health care.