Healthcare Reform in the U.S.
Our General Approach to Policy Solutions
The Institute for Cultural Evolution’s position on healthcare reform, like all the issues in our evolving platform, is focused on finding “win-win-win” solutions that integrate the values of all three major American worldviews: progressive, modern, and traditional. This win-win-win political framework is derived from the business practice of stakeholder integration, which has proven to be highly effective at building agreement and increasing the “size of the pie.” Because the issue of healthcare has become mired in the culture war, sympathetically overcoming political opposition to reform proposals is the first order of business. Which is why outlining an healthcare “win” for all three worldviews is the primary focus of our current proposal.
Our strategy entails evolving and developing this approach to healthcare reform with the goal of forging a rough consensus within the nascent post-progressive political movement. Once agreement is reached among post-progressives, we will then propose this policy consensus to the larger American electorate. So rather than stating a fixed position, this proposal serves as an invitation for deliberative dialogue within the emerging post-progressive agreement space. We thus invite readers to enter this dialogue in the comments section below, on social media, and wherever political ideas are debated. This proposal will accordingly be refined and improved as the consensus it seeks begins to take shape.
Problems to be solved
Higher Costs, Worse Outcomes
America’s healthcare system is exorbitantly expensive. The U.S. spends nearly twice as much on health care as a share of its economy compared to other developed nations. U.S. health outcomes, however, are worse, with the lowest life expectancy and highest rate of chronic disease among developed countries. Healthcare prices are frequently hidden or opaque, administrative costs are bloated, too much is spent on high-tech end-of-life interventions, and the system is burdened by predatory malpractice litigation.
Adults in the U.S. are more likely than those in other developed countries to go without needed health care because of costs. In a 2018 study, the U.S. ranked 29th in healthcare access and quality.1
Reforms Are Stymied by Political Gridlock
Despite healthcare reform being a top issue for both Democrats and Republicans, the issue is hyperpolarized, with each side exercising an effective veto on the positive proposals of the other.
Wins Sought for Each Major Worldview
A win-win-win policy for improving America’s healthcare system would ideally achieve the following wins for each worldview:
- Provision of universal coverage would ensure that every American has access to healthcare, and no one is left behind.
- Costs for the poor and marginalized would be reduced.
- The increased use of market mechanisms would be employed to control costs and increase personal responsibility.
- By keeping the healthcare system connected to the private sector, business incentives for innovation would be preserved.
- A combination of public and private funding would avoid the bureaucratic downsides of an entirely government run system.
- Incentives for self-reliance and personal responsibility would help prevent abuse of the system.
- Rural communities would receive better healthcare.
- Attempts to create socialized medicine would be defeated.
An Example of a Potential Policy Solution: The Swiss Healthcare System
A model for reforming the U.S. healthcare system, which could deliver wins for all three worldviews, is found in the Swiss healthcare system. This system, known as Santésuisse, is a private/public funding solution that provides universal care. In the U.S., this Swiss economic model could be combined with other programs designed to promote and facilitate healthier lifestyles based on better eating habits and regular exercise.
Switzerland has guaranteed comprehensive medical treatment to all Swiss residents since 1996. But unlike many of the state-supported European systems that provide universal coverage, Santésuisse receives most of its funding through the private sector. This system, however, is also subsidized by local governments, which influence and regulate premiums and medical costs.
As Kevin Williamson writes in the National Review: “Santésuisse, achieves one big progressive goal—universal health-insurance coverage—while offering much to please conservatives: a private market for health insurance and health care, consumer choice, and relatively low government spending on health care.”2
The economic viability of the Swiss healthcare system is predicated on mandated private health insurance for all citizens. When coverage cannot be denied for preexisting conditions, insurance mandates cannot be avoided. Health-insurance premiums for lower-income residents, however, are subsidized. By eliminating employer-supplied health coverage, the Swiss system creates a dynamic, consumer-driven insurance market which benefits from the discipline of market mechanisms. The system also carefully controls the costs of medical procedures and requires that all prices be made public, which facilitates market-based consumer choices. The system also employs high copays and deductibles, which incentivizes the use of personal discretion in the consumption of healthcare.
The Swiss health insurance mandate is much more stringent than the current U.S. insurance mandate. “If you fail to comply with the mandate, the Swiss government will garnishee your wages and charge you a penalty equivalent to the cost of the premiums plus up to 50 percent, and, if you persist, the government will sign you up for an insurance policy and allow the provider to sue you for back premiums covering the period during which you were uninsured.”3
Proactive Efforts to Increase America’s Health
Under this proposal, federal, state, and local governments’ efforts to promote healthy eating and exercise would be expanded. These government programs would be supplemented by grants to nonprofit and private sector organizations working to build social norms and encourage habits that result in healthy lifestyles and primarily plant-based diets.
Previous federal-level health improvement initiatives include the following examples: In 2018, as provided by the Affordable Care Act, the FDA began requiring all chain restaurants and other food establishments with 20 or more locations to post detailed calorie counts on their menus.4 In 2012, the USDA improved the nutritional requirements for its National School Lunch Program, and expanded its Supplemental Nutrition Assistance Program (SNAP) to include farmers markets.5
Numerous state and local governments have also encouraged physical exercise through the development of greenways, and by building pedestrian and cycling infrastructure. Local governments have also encouraged healthy food choices by working to eliminate “food deserts” in distressed communities. For example, in 2010 the city of Baltimore created a Food Policy Initiative, which brought together its Department of Planning, its Office of Sustainability, its Health Department, and the Baltimore Development Corporation to “improve health outcomes by increasing access to healthy affordable food.”6
Post-Progressive Persuasion Strategies
Admittedly, many American voters like their employer-supplied health coverage and will thus resist its replacement by a system that mandates private individual health-insurance. However, the growing problems of the current U.S. system, the increasing demand for universal coverage, and the win-win-win framing of this post-progressive approach to the issue (outlined above), can generate the requisite political will needed to eliminate the perverse incentives and social inequities inherent in a system that continues to be based on the diminishing provision of employer-supplied health insurance.
Persuading voters who have employer-provided health coverage to sacrifice the familiarity and convenience of their current plan requires these three arguments to be skillfully made:
- It is unacceptable that among developed nations, America’s healthcare system ranks 29th in quality and access. President Obama’s Affordable Healthcare Act has not corrected the problem.
To implement more effective and acceptable reforms to the system, “something’s gotta give.” And all things considered, that “something” should be the elimination of employer-provided health coverage, which would allow for the implementation of the more functional and economically viable healthcare system, based on the Swiss model.
- Even those who are happy with their employer-supplied healthcare need to realize that healthcare is a community good, and America’s broken system ultimately diminishes the quality of life for everyone. Supporting the necessary reforms required to fix the system, even if such reforms are personally undesirable, is therefore the right thing to do.
- Adopting the Swiss healthcare model, as supplemented by proactive health improvement programs, provides a win to each American value frame and is thus the most viable political path to the substantial improvement of healthcare in the U.S.
- Fullman N, Yearwood J, Abay SM, Abbafati C, Abd-Allah F, Abdela J, et al. (Healthcare Access and Quality Collaborators, June 2018). “Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016”. Lancet. 391 (10136): 2236–2271. doi:10.1016/S0140-6736(18)30994-2. PMC 5986687. PMID 29893224.
- Allison Aubrey, “Now That Calorie Labels Are Federal Law, Will We Eat Less?,” NPR, May 7, 2018, available at https://www.npr.org/sections/thesalt/2018/05/07/609052865/now-that-calorie-labels-are-federal-law-will-we-eat-less; U.S. Food and Drug Administration, “Overview of FDA Labeling Requirements for Restaurants, Similar Retail Food Establishments and Vending Machines,” available at https://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/LabelingNutrition/ucm248732.htm (last accessed October 2018).
- Farmers Market Coalition, “Supplemental Nutrition Assistance Program (SNAP),” available at https://farmersmarketcoalition.org/advocacy/snap/ (last accessed October 2018).
- City of Baltimore Department of Planning, “Baltimore Food Policy Initiative,” available at https://planning.baltimorecity.gov/baltimore-food-policy-initiative (last accessed November 2018). Research sourced from: https://www.americanprogress.org/issues/healthcare/reports/2018/11/27/461418/public-policies-promoting-healthy-eating-exercise
Single payer healthcare is the ONLY solution. There should be no market or private insurance. Period. Private hospitals can exist but the only insurance available should be either federal or state sponsored. There should be no plans, no co-pays, no fees, no deductibles and absolutely no patents on medication and pharmaceutical advancement. It’s supposed to be a healthcare system not an industry designed to make profit off of pain and suffering.
On the post-progressive model, we need to respect the values of all three world views. How would single-payer incentivize innovation and personal responsibility?
Further wonderings: How would single-payer incentivize innovation and personal responsibility without skewing functionality toward profits? Would it be possible to use something like a triple bottom line structure (people / planet / profit)? Or judge success based on Bhutan”s GNH measure (Gross National Happiness) rather than America’s GDP?
Public option, probably based on extended Medicare but coexisting with private insurance market (but not employer-sponsored and not-for-profit as it was originally envisioned) could satisfy all three world views. The bigger issue, though, is how to address the chronic shortage of healthcare professionals in the country. This issue is not even mentioned, but if it is not solved, no insurance system will be able to reduce costs and improve access to care.
A key value is whether health care should be a profit making business or a non profit human service? This is a moral choice. What was once a non profit human service has developed over the last 50 years into a profit making business corrupting health care’s primary mission and value base.
The post progressive integral approach must include a transformation to a non profit human service approach based on a moral imperative of justice, equity, and compassion for all. If profit incentives continue to be allowed and used, they must be highly regulated to insure the common good and not just self interest is served.
This common good of promoting the healthiest functioning possible for all members of society is something that all three world views can agree upon. The disagreement will be on how this goal is to be achieved and who can manage the system developed for their personal benefit. The incentives created and developed must serve the needs of individuals, groups, communities, and society. How can this alignment be designed and implemented is the bigger question which must be answered?
In my view the key value should be to provide “Good quality healthcare to all who need it”. The question then becomes how can that be best achieved? Do you use a for-profit or non-profit model? Both have their advantages and disadvantages. By keeping that decision a pragmatic one rather than a moral one, might it then make agreement more likely?
As a mental health provider the question often is raised about what is more important the mission or the money? The business managers state “without the money, there is no mission.” This makes providers prostitutes willing to design their practice based on money rather than what is best for patients.
There are limited resources and there is creative tension between effectiveness, efficiency, and stakeholder satisfaction. We all want good outcomes, cost competitive , that are stakeholder satisfying. The bumper sticker reads, “Good, cheap, fast, pick two.”
The health care system has been commercialized with physicians and patients now being called “providers” and “consumers.” Health care has become a transaction rather than a professional service imbued with an ethical concern for patient well being.
This is a world that many physicians and therapists are leaving because they went into the healing arts to help people and their practice has been taken over by business managers who dictate the “procedures” they can provide based on reimbursement schedules from insurance companies.
Undermining the ethical basis for patient care degrades the quality of care provided and received.