Better Bang for the Buck

  ·  Health Policy Hub   ·   Michael Miller

Now What? (Part Two)

Getting Better Bang for the Buck

Now that open enrollment is over, it is time for consumer advocates to consider what comes next in health care reform. In a previous blog, we discussed work that still needs to be done to make the next enrollment period an even bigger success so we can continue to chip away at the number of uninsured as well as the importance of continuing to push back against the disinformation about the Affordable Care Act. This blog kicks off a new featured series on Health Policy Hub, Better Bang for the Buck, looking at the interrelated issues of health care costs and quality from a consumer point of view.

With all its challenges and flaws, the Affordable Care Act represents a great leap forward in the effort to ensure access to health coverage for all Americans. Millions who would have been denied coverage because of their health or because they couldn’t afford coverage now have better access to care and their risk of bankruptcy related to catastrophic medical expenses will be vastly reduced. Of course, there is still a long way to go before everyone in the United States is covered. But our ability to achieve that goal and even to sustain the coverage expansion we have won thus far depends on making the system more efficient.

Paying More Getting Less

The U.S. spends twice as much on health care per capita than any other western democracy, a difference that can’t be attributed to an aging population, higher incomes, or greater utilization of health services (CMWF May 2012). Our health outcomes don’t reflect this though. They are mediocre on average and highly variable. On some measures and for some populations, health outcomes in the U.S. more closely resemble those you would see in a third world country instead of an advanced industrial nation. For example: The U.S. ranks 40th among all nations in infant mortality according to the World Health Organization. Life expectancy in Georgia is lower than in Morocco or Libya and in some counties is lower than the Gaza Strip or El Salvador.

Our health system is rife with quality gaps as well as significant health disparities among lower-income populations and racial and ethnic minorities. And what’s especially disturbing is that those quality gaps and health disparities persist even after controlling for health insurance status. As consumer advocates, we must confront that coverage is necessary for providing an equal opportunity at health for all Americans, but that it’s only one piece in a big and complicated puzzle.

Consumers need to be at the table

Although consumer advocates are becoming more engaged in debates on how to change health care financing and delivery to improve quality and reduce costs, the level of engagement doesn’t approach that devoted to the issue of coverage. This has to change if we want to realize the goal of quality affordable health care (and better health) for all.

First, much of the public policy debate revolves around simplistic and dangerous false premises such as: “The reason our health care costs are so high is that consumers don’t have enough skin in the game.” Or “We can’t afford current levels of public health coverage without crowding out other national priorities.” The “solutions” to “problems” like these are to increase premiums and cut benefits. This is not only harmful for consumers in general but also particularly damaging to people who are either poorer or sicker than average (or both). For these vulnerable populations, high out of pockets (even with the ACA) are part of the problem, not part of the solution. 

Without a stronger consumer voice in the debate, federal and state policy makers will gravitate toward solutions that are harmful to consumers, not least because alternative ideas (such as reducing excessive prices) threaten powerful special interests. If consumers are not at the table, they will be on the menu.

The second reason is the status quo is rapidly fading in the rearview mirror, but what will replace it is still to be determined. Health care delivery and financing are changing, and the ACA has accelerated the pace of change both due to the competitive incentives in the Marketplaces and via changes in Medicare and Medicaid. Given its current shortcomings, we ought not mourn the passing of the old system. Instead we should try to replace it with something better. But whether the changes in financing and delivery will benefit consumers/patients depends on consumers becoming effective players in policy debates that have been dominated by providers and payers up until now. Consider two current market trends among many: health care industry consolidations and health plans with narrow networks. Industry consolidation is a two-edged sword from a consumer point of view. Ideally more integrated and coordinated delivery systems will improve patient care and reduce costs. On the other hand, networks of providers that have a dominant position in their local areas can demand higher prices from insurers, which would just translate into higher premiums for consumers with no benefit. Narrower networks could offer good value for consumers and put downward price pressure on premiums. Or narrow networks could create barriers to access, lead consumers to go out of network (and face much higher out-of-pocket costs) and be a tool insurers could use to try to discourage enrollment from sicker patients.

In the end, whether the policy debates on health care costs and the market changes currently underway do more harm than good depends on consumer advocates getting more involved in shaping their direction. But this is easier said than done. That is where this blog series comes in. The goal of Better Bang for the Buck is to help advocates effectively engage in the policy debates around our changing health care system, first by helping to define the problems and offering solutions from a consumer point of view and secondly by sharing the strategies that advocates around the country are already using to effectively engage on the issues of cost and quality.

If consumers can engage successfully in these debates, we can build something better than we have now—a system that produces good outcomes, reduces or eliminates persistent racial and ethnic health disparities, and helps people live healthier lives.

Coming next: Health Care Costs: What is the problem (and what isn’t)?