Why Not Universal Coverage?

Imagine if you decided to quit your job. Or if you were fired? What if you wanted to start a new business? Or go back to school? Or take a few months for travel or to write the next Great American Novel?

How would you maintain health insurance coverage for yourself and for your family?

You might get expensive COBRA coverage. You might go to healthcare.gov (when it is not down for maintenance) and find insurance on the ObamaCare exchange. You might go without insurance for a while and hope that you and your family do not get sick or injured.

But what if your health insurance were guaranteed to you and your family as a public good? Would you be more inclined to start a new business? Or get more education or job training? Or spend more time volunteering or pursuing something creative? What if you had less stress about finances or the unexpected?

Now picture a Congress that has more time, energy, and political capital to address the most pressing needs of the country and the world -- climate change, crumbling infrastructure, corporate greed, income inequality, poverty, famine, displacement, violent conflict -- because they are not fighting over health care.

Finally, imagine if, as a country, we spent 9.7% of GDP on health care like the UK, or 11% like Sweden, or 10.9% like Japan, or 11.3% like Germany, or 9.6% like Australia instead of 17.2% of GDP on health care (data from Organisation for Economic Co-operation and Development). If we spent only 12% of GDP -- still more than other OECD countries (except Switzerland, 12.4%) -- on health care, we would save almost $1 trillion every year and $10 trillion over 10 years.

How to spend that money is for another post, but for some perspective: we could rebuild the entire US highway system twice over every year, or pay off the national debt of almost $20.5 trillion in 28 years, or give our 3.2 million public school teachers a $300,000 raise.

1. Guaranteed health care. 2. Lawmakers focused on other major national and world problems. 3. $1 trillion in savings. This is the dream of single-payer advocates, such as Vermont Senator Bernie Sanders.  For the average American, it's win-win-win-win: greater economic and personal freedom, less stress, fewer medical bankruptcies (or none!), no news stories about the next GOP attempt to trash ObamaCare, more public and private dollars for investments in America's and the world's future.

So what is the hold up? One trillion dollars every year. The difference between what we spend on health care (17.2% of GDP) and what other wealthy countries with excellent health care spend (12% or less) is $1 trillion of fat that now goes to insurance companies, hospitals, pharmaceutical companies, medical device manufacturers, nursing facilities, pharmacists, doctors, shareholders of the medical-industrial complex, and thousands of industry lobbyists. A lot of people are made wealthy by the inefficiency of our health care system. And, right now, these powerful interest groups have more sway with lawmakers and public opinion than single-payer advocates.

That is starting to change.

Up next, driving the change to single-payer.

An Ounce of Prevention Is Worth One Pound Eight Ounces of Cure

NPR reported this morning on a health care system in Pennsylvania -- Geisinger -- that is helping its diabetic patients by prescribing fresh foods. They are seeing dramatic improvements in hemoglobin A1c, a marker of blood sugar control, and expect to reap $24,000 in savings for each $1,000 spent on the program.

That loud bang you hear is not a secret airplane landing with a sonic boom but the sound of public health researchers and advocates smacking their foreheads. The public health community has long been pushing for upstream interventions to improve health, like improving access to fresh foods, building safe communities so people can be outside getting exercise, getting tobacco out of public spaces.

This is not to diminish what Geisinger is doing. On the contrary, we need more health systems to innovate in preventive care. But under the traditional payment model -- where every widget (or toe amputation) is reimbursed -- health care organizations stand to make more money treating sick patients than they would keeping populations healthy.

Over the last three decades we have made gradual progress in changing the incentives to encourage more preventive and higher quality care. Hospitals are paid for bundles of service, e.g. heart bypass surgery and rehabilitation, and are on the hook for preventable complications such as post-operative infections. Some health systems provide standard per member per month (or PMPM) payments to health care providers to keep their populations healthy and care for them when they are sick. The Affordable Care Act mandates that health insurance pay for certain 'essential health benefits,' including preventive care such as pediatric well-child visits.

The Geisinger experiment and public health research show that we should be investing a great deal more in keeping Americans healthy and preventing illness in order to reduce suffering and death. And save money.

In its current form, the Republicans' health care reform bill, the AHCA, gives millions of dollars in tax breaks to the wealthy and drops essential health benefit coverage.

This will cost us.