Opinion | A Republican Argument for Affordable Universal Healthcare

Even fully in power in 2021 and 2022, Democrats and President Biden could not do a great deal on healthcare reform because of razor-thin majorities. There were some accomplishments, though. Exchange premium subsidy enhancements were passed twice and now are extended through 2025. President Biden used his significant regulatory authority to expand outreach and marketing in the Affordable Care Act (ACA) exchanges as well as extend enrollment periods. He has now announced a special enrollment period into 2024 due to looming Medicaid redeterminations beginning in April. He also used his regulatory authority to push Medicaid population and benefit expansions. This helped expand enrollment in the exchanges, Medicaid, and the Children’s Health Insurance Program (CHIP) to well over 100 million Americans.

But with the change in control of the House to the GOP, prospects for sweeping healthcare reforms are now all but dead for the next 2 years. Indeed, we may take some steps backward. With the end of the public health emergency coming, Medicaid redeterminations will again occur. Throughout the pandemic, eligibility rules were suspended once someone was enrolled in Medicaid. They will come back beginning this April and up to 18 million (depending on the study) could lose Medicaid coverage in 2023 and 2024. Historically, conversion to other coverage (state children’s health coverage, exchange, and employer) has been low, in part because enrollees do not understand the redetermination process and have little awareness of other healthcare programs. That could change with richer premium subsidies in the exchange. But, after substantial progress on the coverage front the past few years, our uninsured rate will undoubtedly increase by millions. More broadly, Republicans in both chambers traditionally have taken a dim view of government healthcare programs. They seem to be advocating for very different things when it comes to coverage and access.

With so much at stake on the healthcare coverage and access front, here is my appeal to Republicans — my own party — to look differently at affordable universal healthcare coverage. There are many great Republican reasons to do so.

Access Is a Prudent Investment

If you are wealthy or have good coverage, America is the place to be if you have a health episode. People flock here for the on-demand care, advanced technology, and expertise in our system. But if you are an average American, as the great healthcare economist Uwe Reinhardt titled his seminal healthcare work, you are Priced Out. We spend the most of any developed nation. But, because of high costs, a lack of focus on prevention and wellness, gaps in coverage, and periods of being uninsured, Americans have among the lowest outcomes in the developed world. The Commonwealth Fund validates this frequently.

The truth is that upfront coverage would help America focus on wellness, prevention, and care management. Care might, in time, move from emergency room and inpatient chaos to relationships with primary care physicians and specialists — where care is relatively cheap and disease and conditions can be caught early. Again, the Commonwealth Fund shows how pushing care lower in the system means demonstrably better results on controlling chronic conditions, reducing hospital admissions, and more.

I am not a proponent of abandoning the employer system, but true affordable universal access could take some of the fracture, duplication, and costs out of the system. Over time, the paradigm shift could bring us closer to the developed world norm of spending 9% to 13% of GDP on healthcare rather than about 18% and headed to nearly one-fifth.

Economic Competitiveness

The system we have today threatens our economic competitiveness.

While American business has always been mighty on the world stage with great labor productivity, there is no question that healthcare costs are weighing down America’s competitiveness. America is the only nation in the developed world to have a predominantly employer-sponsored healthcare system and that comes at great cost to businesses. While businesses can deduct healthcare costs from taxes, it is not a dollar-for-dollar tax credit. Thus, businesses bear the lion’s share of employer healthcare coverage costs. While some developed world countries levy some costs to business (e.g., Germany), American businesses have a much larger burden. In addition, employer coverage also bears some “cost-shift” from Medicare and Medicaid due to lower reimbursement rates in those programs. Because reimbursement in the government programs is poor, providers ask insurers and employers for additional payments in commercial products to make up for it. This drives up commercial insurance costs. Some debate the extent of cost-shifting.

Thus, American business has a triple whammy when it comes to its unique healthcare burdens — the costs of employer-sponsored coverage, the cost-shift from other healthcare programs, and high annual inflation due to an expensive and unaccountable system.

Universal Access Does Not Mean Socialism

Universal access does not mean moving to a socialist system. There are three working and high-functioning models in the world: socialized medicine, single payer, and private universal access. Many western countries have private affordable universal access. The Commonwealth Fund study above concluded that Norway, The Netherlands, Australia, and the U.K. had the highest overall rankings for healthcare system performance. They represent each of the three working systems noted. Thus, all three can be efficient and have great healthcare outcomes. We can keep a private system.

Affordable Universal Access Is Connected to Personal Responsibility

Adopting affordable universal access does not mean a lack of personal responsibility. Personal responsibility is key to an efficient and high-performing healthcare system. Offering reasonable premium subsidies for those who need it and perhaps helping with cost-sharing are both important. But so are personal responsibility incentives and penalties to ensure that individuals use the system responsibly. As the nation works toward interoperability, price transparency, and using the right site of care for services, personal responsibility will be key to bringing down the overall cost of care. This should be music to Republican ears.

In my book, The Healthcare Labyrinth, I outline three principal pillars for healthcare reform — getting our arms around cost, pivoting from utilization management to care management, and affordable universal coverage and access. Affordable universal access should be the first one we tackle. There have been at least three GOP presidents who have taken up the mantle of affordable universal access: Teddy Roosevelt, Richard Nixon, and George W. Bush (he delivered Medicare Part D drug coverage).

Roosevelt declared in his New Nationalism Speech in August 1910: “…Let me add that the health and vitality of our people are at least as well worth conserving as their forests, waters, lands, and minerals, and in this great work the national government must bear a most important part.”

In a 1974 message to Congress on his sweeping healthcare plan, Richard Nixon stated: “Without adequate healthcare, no one can make full use of his or her talents and opportunities… For the average family, it is clear that without adequate insurance, even normal care can be a financial burden while a catastrophic illness can mean catastrophic debt…Comprehensive health insurance is an idea whose time has come in America.”

Even back in 1974, Nixon knew the average family was being priced out of quality and affordable health insurance. He knew it was a social good to have reform. Indeed, reform’s time has more than come.

Will my party wake up and drive compromise? I hope so. It is both compassionate and makes great fiscal sense. It is all about giving people a leg up and not a handout. Back in 1975, Republican policymakers designed the earned income tax credit. It was signed by Republican President Gerald Ford and expanded by Republican President Ronald Reagan. Healthcare reform can be a Republican issue too.

Marc S. Ryan, MPA, is a veteran health plan and healthcare technology executive as well as former government official. He is the author of The Healthcare Labyrinth.