A new “Perspectives” article published in The New England Journal of Medicine online puts the current policy landscape around the U.S. healthcare system into an international frame, for broader context, with the industry leader arguing that the United States needs to move forward in broadly configured, ongoing healthcare reform, moving forward.
“Health Care as an Ongoing Policy Project” was published on July 30 by Eric C. Schneider, M.D., M.Sc., who is senior vice president for policy and research at The Commonwealth Fund, a New York- and Washington, D.C.-based organization described on its website as “a national philanthropy engaged in independent research on health and social policy issues.”
After acknowledging in the opening paragraph of this Perspective that The U.S. healthcare system offers “top-flight medical training,” that “Many of its hospitals offer the most advanced medical and surgical care for dire, acute, rare, and once-lethal conditions,” and that the U.S. “spends more per person on healthcare than any other country,” Dr. Schneider notes that, “Despite these assets, the United States lags behind other high-income countries on health outcomes such as life expectancy, childhood health, and avoidable deaths. For too many Americans, the quality of care is not optimal. Access to basic care is out of reach for many. The costs of care, escalating for decades, are increasingly intolerable to those who pay the bills, whether governments, employers, or individuals. American health care is also inequitable, with gaps in insurance benefits and quality of care consigning people of color, people living in poverty, residents of rural areas, immigrants, and LGBTQ people to worse care than others.”
In addition, Schneider argues that “Many gaps widened even while the nation was prospering. The Covid-19 pandemic is bringing these and other weaknesses of U.S. health care into stark relief. Americans have struggled for over a century to solve this riddle and bring about a high-performing, affordable health care system. Some progress has occurred, but many Americans believe that additional reforms are needed.”
In this article, Schneider argues that, in order for any country “To produce better health outcomes, the key areas of performance include the structures that support care (the workforce and organizations that deliver care, and payment systems); the processes used to deliver safe, effective, patient-centered care; and whether people have timely access to that care. Crucially, care should be delivered equitably.”
Looking at overall national healthcare system quality through that lens, Schneider states that “Overall, the quality of care is worse in the United States than in several other high-income countries, and Americans’ health status and outcomes are worse than those of their counterparts in those countries.2 Much of the difference is due to social factors outside the health care system. As compared with other countries, the United States spends less and more unevenly on social supports such as child care, housing support, nutrition, transportation, parental leave, unemployment, and other social safety-net programs.3 As a result, Americans have higher rates of obesity, chronic diseases leading to preventable illnesses, complications, and deaths. U.S. life-expectancy trends have lagged behind those of other countries, and even recently fell for 3 consecutive years amid an increase in deaths due to alcohol, opioids and other drugs, and suicides. Many preventable conditions go untreated as persons such as the elderly woman described above delay seeking care. On average, U.S. maternal and infant mortality rates are higher than those in many other countries.”
And, in that context, he writes, “For a population facing such formidable health challenges, access to care is a key problem. The United States lacks the universal insurance coverage available elsewhere. Public insurance programs cover the elderly, disabled, and poor, but publicly insured patients struggle to find clinicians, particularly specialists, willing to accept them because the government pays lower rates than commercial insurance. As the current pandemic illustrates, the tie between employment and private health insurance means that millions of Americans can lose coverage during periods of economic recession and growing unemployment. Out-of-pocket costs have been rising, too, as high copayments and deductibles — designed to make consumers more cost-conscious — have proliferated. Many Americans fear unexpected medical bills and debt.”
Schneider argues that, given the unique, complex mix of public an private aspects of healthcare payment and delivery in the U.S. system, that public policy leaders must find ways to manipulate the “levers” of the U.S. healthcare system in order to improve the situation for many millions of Americans.
“In most high-income countries, governments fill the gaps where markets fail,” Schneider writes. “For example, the United States provides insurance to elderly and disabled people (through Medicare) and poor people (through Medicaid) who could not afford it otherwise. But rather than operate facilities (as the government does for military veterans), the U.S. federal and state governments generally use purchasing and information-transparency strategies to try to foster competitive health care markets. Governments may also serve as a backstop, providing the dollars that keep private hospitals and professionals in operation during disasters (such as hurricanes or pandemics) or covering extreme costs for very sick patients through reinsurance to keep premiums from skyrocketing.”
Importantly, he notes, “Americans are increasingly concerned about health care. Polls show that they are especially dissatisfied with the costs they face personally. Many Americans have begun to view high-quality health care as an opportunity available only to some people, a financial burden for many, and an unsafe and financially ruinous ordeal for others. But a health care system is not immutable. It can be changed through policies. In future articles in this series, experts will further describe the problems with quality, equity, and cost; explore solutions; and reflect on the policy levers that can help bring about reforms.”
And, with regard to the pandemic, Schneider concludes that “The Covid-19 pandemic reminds us that the dedicated health professionals delivering care every day are the indispensable part of any health system. Without their motivation and dedication, access to high-quality, equitable care would not be an option. But sound health policies are also indispensable. They shape the delivery system, strongly influencing whether someone like the elderly woman with chronic health problems and new and worrisome symptoms decides to suffer at home, delaying until it is too late, or seeks care when it can be most effective. And health policies set the terms under which health professionals can provide high-quality care that achieves her health goals at a price that she and society can afford.”
On its website, The Commonwealth Fund notes that “The mission of The Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries.”
