In this year’s election, the American people were presented with a stark choice about the future of this country. When they cast their ballots, they were not just choosing a president—they were deciding what defines us as Americans, how we relate to other nations and to the environment, the role of government in our daily lives, and yes, the path forward on health care. With a new president and administration coming in, there will of course be some reprieve from the constant assaults on the Affordable Care Act (ACA). But even so—and putting aside the pending Supreme Court case seeking to overturn the law—it would be a mistake to believe that all will now be well in our world of health care. The reality is that we still face a long road ahead.
The immense challenges confronting our health care system preceded the current administration: the millions of people who still fall through the cracks of our patchwork insurance system; the high and rising costs of medical care, not only out-of-pocket costs for consumers but expenses for employers and federal and state government; and the wide disparities in health outcomes, especially for Black and Brown communities.
A PANDEMIC, A RECESSION, AND A MOVEMENT FOR SOCIAL JUSTICE
These challenges have been greatly exacerbated over the past few months by two powerful forces: the COVID-19 pandemic and the resulting economic recession. The urgency in meeting them has also been highlighted by the rising strength of a social justice movement combating anti-Black racism. The pandemic showcased both the heroism of individual health care providers, but also the limits of a fragmented health system’s ability to offer a coordinated response to a large-scale public health crisis. It has also financially weakened almost all parts of the system, with full recovery likely years away.
The recession has exposed the fragility of an insurance system that relies heavily on employer-sponsored coverage. It has all but erased the memory of our celebration of New York’s lowest-ever uninsured rates just prior to the pandemic. And the social justice movement has laid bare many of the inequities that have led to persistent disparities in health outcomes, with the different rates of COVID-19 morbidity and mortality among Black and Brown communities being just one more example of the deep impacts of structural racism.
Although these additional threats to our health care system would have existed under any administration, in another, they would not have been compounded by constant attacks on the ACA. One can also reasonably argue they would have been mitigated with a more effective federal pandemic response, as well as one that sought to address inequities rather than inflame divisions.
HOPE FOR PROGRESS
What can we expect moving forward? There will be no miracle cure for our health system, but we can now hope and work for progress. In addition to promising science-based federal leadership for the pandemic response, president-elect Biden ran on a platform of not only embracing the ACA but building on it. A Biden administration has plans to expand coverage through a new public health insurance option, increase subsidies to make insurance premiums more affordable for middle-class families in the individual marketplaces, and provide insurance to those low-income Americans living in states that elected not to expand Medicaid under the ACA. However, with a most likely divided Congress, making progress on these efforts will be immensely challenging—particularly in light of the competing priority of addressing the ongoing pandemic. The details will determine not only the overall costs of this coverage expansion to taxpayers but also the impact on providers, who may be wary of another insurance option that reimburses for care below their costs. Regardless, we may once again be on a path toward expanding health insurance coverage, reversing a trend from the Trump administration.
Tackling health care costs will be less straightforward. It is one thing, as the Biden team proposes, to try to address specific out-of-pocket issues for consumers, like “surprise billing,” or limited components of health care costs, like prescription drugs. But tackling overall health care costs will be much more difficult, with no clear path in sight. Efforts like value-based payment or price transparency are generally not partisan issues, but they have also shown to be of limited effectiveness. Expansion of public insurance options as proposed may dampen cost growth—especially if they crowd out commercial insurance—but this will also likely stir up provider opposition.
TACKLING HEALTH CARE DISPARITIES
The most difficult challenge will be addressing health care disparities, especially among Black and Brown communities. Yes, expanding insurance and targeted initiatives, such as the proposed Biden plan to reduce disparities in maternal mortality, will help. But the drivers of disparate health outcomes are much deeper than that which can be solved by the health care system alone. They relate to inequities in the social determinants of health—housing, education, nutrition, employment, and wealth—which in turn are largely related to structural racism in this country. But there is reason for hope here. The incoming administration has explicitly identified tackling systemic racism and advancing racial equity as part of their agenda, cutting across multiple sectors.
Yes, it’s a long road ahead. But at the very least, I believe that we are finally going in the right direction again.