If Healthcare Is a Human Right, How Do We Get There?

If healthcare is a human right, how do you pay for it in the United States so that no one is left behind?

In a session called “Single-Payer Healthcare: Is It the Right Approach for the US?” at the 2018 National Health Policy Conference of America’s Health Insurance Plans in Washington, DC, a panel tried to come up with an answer to that question, as well as others; but first, a leading proponent of a single-payer system laid out a premise for the audience.

In the view of Donald M. Berwick, MD, MPP, president emeritus and senior fellow, Institute for Healthcare Improvement, healthcare policies and payment designs should be driven by purpose. However, the former CMS chief called healthcare “massively defective—it cannot achieve better care for individuals and populations at lower cost.”

In his view, there are 4 improvements that have to happen:

• Reduce non—value-added cost
• Create proof of patient safety
• Rebalance delivery of care so that it is home-based, community-based, prevention-oriented, and incorporates social determinants of health
• Embrace innovations like telehealth

“We are treating effects of American healthcare instead of causes," he said to this third point.

Even without being fully implemented, the Affordable Care Act (ACA) was a major step forward to achieving some of those improvements, he said. But he added that our current healthcare payment system is “toxic,” citing fee-for-service arrangements.

He then issued a challenge to the audience: “Is your primary purpose to make healthcare a human right in this country, and to assure the continual improvement of care?”

“I don’t think it is,” he went on, citing what he called one of the clearest bellwethers—the medical loss ratio (MLR)—which he illustrated by noting his efforts to describe it to colleagues in other countries, who find the MLR “insane.”

The conversation around single payer has picked up since last year, when Senator Bernie Sanders, I-Vermont, released his “Medicare for All” plan, and last month, the left-leaning think tank Center for American Progress released a version called “Medicare Extra for All.”

In his opinion, Berwick envisions a public utility structure “an arm’s length” from the government but suggested to the audience, “if I were you, I’d try to define it as Medicare Advantage.”

Berwick asked the audience to think about whether or not they think healthcare is a universal right and does it continually improve the care of individuals and populations. “If you don't believe that, then you're not in the right business.”

Berwick was followed by Douglas Holtz-Eakins, president of the conservative advocacy group American Action Forum. Holtz-Eakins, who headed the Congressional Budget Office under President George W. Bush, said he did not disagree with the premise that healthcare is a human right.

But he said, “we've never had a single-payer system” in any area and noted that the United States is organized around decentralized systems, citing examples of transportation, education, and basic research. He said he concurred with Berwick’s premise, but for him the issue is “which direction do you go?” Polling his organization has conducted shows that people are divided on the idea of single payer, largely along party lines. And in battleground states, swing voters are against the idea.

“I'm skeptical that this is a live policy option in the US,” he said.

Larry Leavitt, senior vice president at the Kaiser Health Foundation, said he credited Sanders for making single payer a topic of conversation, as well as national Republicans, because of their efforts to dismantle the ACA last year. Single payer is now a litmus test for progressive candidates, he said.

He noted that the United States is the only industrialized nation without universal healthcare. Some have systems that also include out-of-pocket costs or private insurer options, like Germany and Switzerland.

In his view, the only way to get everyone covered is to have a single stream of tax-based financing, which he also noted would be “very disruptive” as there would be “winners and losers.” Any system would have to include cost containment, noting that in other countries, prices are lower.

And to Holtz-Eakin’s point about polling, Leavitt said results will depend with how you ask the question. If you present arguments that opponents would likely use, then support for single payer drops. Kaiser’s polling shows majority support for it, he said.

Leavitt said he expects to see new proposals that “blunt opposition” to single payer, citing the one from the Center for American Progress, which still leaves room for private insurance.

The panel was moderated by Len M. Nichols, PhD, who heads the Center for Health Policy Research and Ethics at George Mason University, who noted that Republican attempts to undo the ACA made it even more popular.

“When care being taken away is actually a real possibility, a majority of us do actually do want all our fellow citizens to have access to care,” Nichols said. He asked Holtz-Eakin what that said about the issue.

The ACA was tied to the approval of President Barack Obama, said Holtz-Eakin, who noted, “the moment he left office it became more popular.”

Nichols asked Berwick if his goals could be achieved through a plan like Medicare for All. There needs to be someone standing up for patients, Berwick said.

“Accountability has to be the steward so that people get care and that they get better over time,” Berwick responded. Costs have to fall, and there is no steward right now, he said.