Universal health coverage was a dominant issue during the 2020 Democratic Presidential primary, representing the latest high-water mark in a century-long struggle to make health care a fundamental right in the United States. But even as a global pandemic has shown the urgent need to transform the US health care system, political realities have seemed to put major health reform on the backburner. Americans who remain dedicated to universal health care are left with a vexing question: Where do we go from here?
There is essential work in policy and politics that can be done in the short- and medium-term to pave the way for universal health care in the future and continue to force the conversation about the urgent need to dignify health care as a human right. An important precondition to this work is an ability to rise above day-to-day political skirmishes to maintain focus on the north star of health care for all. The “Comprehensive Healthcare for America” proposal in this issue enters this debate with an alternative approach to near-universal coverage.Reference Sorum, Stein and Moore1 While we applaud these intentions and the effort to bring various coalitions together, here we offer a different roadmap for moving toward truly universal health care in our current political environment.
We propose four priorities as next steps on the road to universal coverage: strengthen Medicare, support universal coverage in the states, build the primary care infrastructure, and support pro-democracy reforms.
Strengthen Medicare
Major expansions of health coverage in the United States will require strong public insurance plans. And yet private interests have chipped away at the size, power, and comprehensiveness of these public plans at every turn. A common feature of recent proposals to achieve universal (or near-universal) coverage — including Medicare for All, the many varieties of a public option, and hybrid proposals like Medicare for America — is that an improved version of a public plan like Medicare is the main source of coverage expanded to new populations. It is therefore strategically important to strengthen the current Medicare program, both to improve it for the millions of people who rely on it today and to pave the way for expansions of public health coverage in the future.
A recent proposal for “Medicare 2.0” outlines a package of reforms that would significantly improve the traditional Medicare program.Reference Johnson and Berwick2 Key elements include streamlining Medicare into a single comprehensive insurance plan, thereby replacing the complex and inefficient system of Parts A, B, D, and supplemental coverage; adding prescription drug coverage to the standard Medicare plan; reducing out-of-pocket costs for patients; and rebalancing payment rates toward primary care. These reforms would create a reliable and comprehensive Medicare program to serve as the basis for future coverage expansions.
A second important area for reform is the Medicare Advantage program, the private (and mostly for-profit) alternative to traditional Medicare that has been growing rapidly in recent years. Medicare Advantage plans cost more for taxpayers3 and propagate the fragmented nature of the US health insurance system. While some analysts have proposed that Medicare Advantage plans could be a basis for health coverage expansion, many universal health care advocates worry that this would grant for-profit insurance companies a major role in a universal coverage system, perpetuating the central challenges we have today. Indeed, in 2020 the Biden-Sanders Unity Task Force and the official Democratic Party Platform explicitly outlined a public option that would not be administered by private companies. The most obvious reform needed in the Medicare Advantage program is to fix the system the government uses to pay Medicare Advantage plans, which insurers have exploited to garner over $100 billion in overpayments over the last twelve years.Reference Gilfillan and Berwick4
We propose four priorities as next steps on the road to universal coverage: strengthen Medicare, support universal coverage in the states, build the primary care infrastructure, and support pro-democracy reforms.
Finally, it will be critical to ensure the successful launch of Medicare drug price negotiations which were passed as part of the Inflation Reduction Act of 2022. The negotiation system developed as part of the Inflation Reduction Act can serve as the basis for negotiations under a future universal coverage system. Beyond building the necessary administrative capacity, drug price negotiation is an extremely popular policy and will provide a highly visible test of greater government engagement in health care. A successful, timely, and transparent launch of Medicare price negotiations will be an important opportunity to garner public trust for future health reform.
Universal Coverage in the States
Given current political conditions, states may be better poised than the federal government to pursue universal coverage policies over the short term. There is also precedent for national health reforms beginning on a smaller scale, such as the Canadian universal health insurance system beginning in the province of Saskatchewan or the Affordable Care Act being based on a Massachusetts health reform.
Whether on the campaign trail or in legislative sessions, recent years have brought significant attention to public option and single-payer plans at the state level. For instance, in 2018, seven nominees for governor proposed state-level single-payer plans, and in 2021 twelve bills were introduced in eleven states to enact a public option plan.Reference Johnson and Kishore5 Furthermore, in November 2022 voters in Oregon approved an amendment to the state constitution stating that health care is a fundamental right for every resident of Oregon.
These developments are promising. With divided government at the national level, the states provide numerous possible frontiers for breaking through on health coverage expansions, and the experience navigating the political and policy terrain will provide valuable practical lessons. Universal health care advocates would be wise to commit their efforts to these state-based initiatives, both in terms of building the political support on the ground for these changes and by shaping the relevant policies at the state and national level.
Primary Care Infrastructure
Beyond simply providing insurance coverage for all, universal health care requires a strong workforce of clinicians able to provide excellent care across the country. Because millions of uninsured and underinsured Americans have been priced out of care for so long, universal health coverage should also be paired with investments in the workforce to make sure patients have access to excellent and timely care once they are finally brought into the fold.
The greatest opportunity for progress on this front is strengthening the primary care workforce and the community health center infrastructure. Primary care is the foundation of a well-functioning medical system, but the US already faces a shortage of primary care clinicians. The problem is especially severe for marginalized populations living in rural and low-income urban communities.
There are two main types of reforms that will help strengthen primary care at the national level. First, we should focus on reforming insurance payment policy, especially in Medicare, to shift resources into primary care. Second, we need direct investment in primary care jobs and infrastructure. One ambitious proposal is to build a federally-qualified community health center in every primary care shortage area.Reference Kishore and Johnson6 In terms of jobs, programs such as the National Health Service Corps (which funds tuition in exchange for primary care service in an under-resourced area) and Teaching Health Centers could be drastically expanded to attract and retain physicians, nurse practitioners, physician’s assistants and other clinicians in primary care. These reforms will help ensure the US has the capacity to deliver universal care once coverage expansions are enacted.
Pro-Democracy Reforms
The movement for universal health care is inextricably bound to the movement to strengthen American democracy. Health reform faces a paradox: policies to expand health care coverage and access tend to be both popular and extremely difficult to enact. This paradox is largely explained by structural features of the American political system. Some of these features are intentionally designed to provide checks and balances in the system, such as the diffusion of power across the President and two chambers of Congress. But in many cases — such as voter suppression, the filibuster, gerrymandering, and big money in politics — the barriers to enacting popular health policies are simply anti-democratic in nature. Legislation such as the For The People Act would represent a significant step forward on these issues, and there are also ongoing efforts in the states to protect democracy such as citizen redistricting commissions to combat gerrymandering. The movement for universal health care should seek to be a stronger partner in the coalition pushing for pro-democracy reforms.
Looking Ahead
The responsibility to provide universal health coverage to the American people will not go away. Opponents have defeated universal health efforts time and time again over the last century of American history, but they have not been able to silence the perennial calls that health care ought to be dignified as a human right. The current political moment is not ripe for a major federal expansion of health insurance. But by bolstering Medicare, supporting reforms in the states, building primary care capacity, and strengthening our democracy, we can make critical progress toward the elusive but essential goal of health care for all.
Note
The authors have no conflicts of interest to disclose.
