Healthcare for All
Healthcare for All
We have a fundamental duty to achieve quality universal healthcare in this country. Despite the significant progress made under the Affordable Care Act, we still have a long way to go to lower cost and improve access to and quality of care. This is why I’m calling for a Primary Care for All system and a robust public option that will reorient our healthcare system towards primary care and away from high-cost and specialty care, improving access and outcomes and reducing costs to achieve sustainable, affordable healthcare.
The U.S. healthcare system currently suffers from three primary problems. The first is the disproportionate and ballooning cost of healthcare, both for individuals and families, and as a proportion of national spending. The U.S. spends more than twice as much on healthcare as other OECD countries. In 2018, we spent $3.5 trillion on healthcare, nearly 18% of GDP, and spending is projected to continue rising faster than GDP growth. Part of these costs are driven by an aging population. However, a significant portion is the result of rising prices for healthcare services which have outpaced growth in non-healthcare-related consumer prices. The rising costs of healthcare are unsustainable for our nation and for individuals and families who spend too much of their income on healthcare.
The second main healthcare challenge is that our health outcomes are consistently worse than other peer nations. We have the lowest life expectancy among all OECD countries, the highest rates of chronic disease, the most avoidable deaths, the highest rates of hospitalization for preventable causes, the highest rates of obesity, and the highest rates of suicide. Not only do we consistently rank lower than our peers, our health outcomes are actually getting worse: life expectancy is decreasing and rates of chronic illness are increasing. The U.S. also has fewer physicians per capita than other countries, a shortage which is projected to worsen significantly in the next 15 years. Our health is not only worse, on average, than our peer nations, but it is also extremely unequal across groups. Black Americans suffer from higher rates of hypertension, diabetes, stroke, obesity, and mortality at all ages than white Americans. American Indian and Alaskan Natives have even higher rates of chronic disease and lower life expectancy.
The third problem is the widespread lack of access to health insurance and healthcare. At least 1 in 10 American adults are uninsured, and these numbers are soaring as unemployment increases. Despite spending significantly more on healthcare than other wealthy countries, many people lack health insurance because they cannot afford it.
We must stop spending more for less.
I’m proposing a reorientation of our healthcare system toward Primary Care for All to rectify these failures of our healthcare system. We can improve health, insure everyone, and reduce cost. This requires changing where and how we invest our dollars in the health system to promote primary care.
Primary care is comprehensive, coordinated, and continuous care of patients by a primary physician and a team of healthcare professionals who provide a patient’s first contact with the healthcare system and manage continuing care. Primary care involves health promotion and maintenance, disease prevention, counseling, mental health, and behavioral health services, and diagnosis and treatment of chronic and acute illness. The primary care physician (PCP) serves as the point of entry for virtually all of a patient’s medical and health needs and then connects or refers patients to other health services or specialist providers as needed.
The Benefits of Primary Care
Decades of research have demonstrated that access to quality primary care improves health outcomes, including increased life span, decreased mortality from cancer, heart disease, and stroke, improved preventive care, and reduced hospitalizations. Access to primary care also reduces disparities related to preventive health care and treatment of chronic conditions, especially in areas with high levels of inequality. Primary care improves outcomes by improving access to and quality of health services, emphasizing prevention, and providing early identification and management of health conditions and coordinated care.
Primary care is also cost-effective. Access to quality primary care reduces the utilization of, and need for, high-cost services. It also reduces the severity of illnesses, meaning that patients lose less time to illness and treatment. Primary care is less technology-intensive than specialty and hospital care, which also reduces cost. As the first point of contact for patients, primary care also reduces unnecessary specialist care and lab testing, and the existence of more primary care practices combats healthcare consolidation that leads to higher prices.
U.S. Primary Care is in Crisis
Despite the clear benefits of primary care, primary care practices in the United States are in crisis. Although primary care services account for a majority of all healthcare encounters, primary care accounts for only 5-7% of total healthcare spending. Other wealthy countries spend twice as much on primary care on average. This imbalance in funding is due in part to complex fee-for-service payment structures that privilege in-person visits and services provided by specialists and fail to compensate primary care specialists for most care services provided to patients not in the office, such as phone and email consultations and other types of coordinated distance care. These payment structures also increase the administrative burdens on primary care practices, resulting in just a quarter of primary care physicians’ time spent interacting directly with patients, and the majority consumed with billing and records-keeping.
The lack of remuneration and high administrative burden on primary care providers contributes to a persistent and growing shortage of primary care physicians. The U.S. already has 50% more medical specialists than primary care generalists, and the shortage of primary care physicians is projected to reach more than 50,000 by 2035. The shortage is driven by significant numbers of PCPs reaching retirement in the coming years and by fewer medical school graduates specializing in primary care, many of whom cite the significantly lower salaries in primary care as a disincentive. Already struggling primary care practices around the country are facing particularly acute economic challenges as a result of the drop in in-person visits due to Covid-19. Just as access to quality primary care improves health outcomes, decreased access and reduced quality of care from overburdened providers and practices will continue to worsen U.S. health outcomes.
And finally, the U.S. suffers from unequal access to primary care. Racial and ethnic minorities and rural residents have less access to primary care. Black, Hispanic, and Asian Americans are much less likely to report having a usual source of care and to identify a specific person as their usual provider of care. This disparity in access to primary care leads to greater use of hospitals as points of care and therefore increased health-related financial burdens, as well as worse health outcomes. The shortage of primary care providers and the funding disparities between primary care and specialty or hospital medicine makes increasing access to primary care for underserved populations challenging. Federal investments in primary care for underserved populations, primarily through Community Health Centers, has been proven to improve health outcomes and reduce hospitalizations. However, the overall disinvestment in primary care and shortage of providers means that unequal access persists.
The evidence is clear: right now, the U.S. spends too much of its healthcare budget on specialty services, hospital care, and administrative tasks, and not enough on the services that generate improvements in health and savings. These imbalances are threatening population health and driving up costs. Quality primary care is good for our health, and good for our economy.
Toward a Sustainable Primary Care for All Healthcare System
We need to increase access to, and utilization of, primary care services by both increasing the capacity of existing primary care practices and increasing the supply of primary care providers. Changing how we invest in healthcare can accomplish these goals.
Increasing Investment in Primary Care
Increasing access to primary care must begin with increased investment in primary care. I support mandating a minimum threshold of spending on basic primary care relative to total healthcare spending for all insurers. OECD countries spend an average of 14% of their healthcare expenditures on primary care. The U.S. spends less than half that. Increasing the portion of healthcare spending on primary care will increase access to care by improving salaries for primary care providers, thereby attracting more providers, and providing primary care practices with the capacity to hire additional staff. Moreover, research shows that these increased investments in primary care almost always pay for themselves through savings in preventable hospital and emergency department care and avoidable surgeries. Rhode Island has implemented primary care spending mandates and realized healthcare cost savings while increasing overall spending on primary care, and several other states are looking to follow suit. I believe we must rely on evidence to guide efforts to improve healthcare, and the evidence is clear on the payoffs to investing in primary care relative to hospital and specialty care.
In addition to increasing investment in primary care as a portion of total spending, I support creating a student debt forgiveness program available to medical students who work in primary care in underserved areas characterized by low densities of primary care providers. With an average medical student debt burden of nearly $200,000, the high-cost, low-compensation environment that typically characterizes primary care in underserved areas makes the physician shortage particularly acute in areas that most need care. We must improve the allocation of primary care physicians to reduce costs and improve outcomes, and this program would make it feasible for more students to opt for primary care service.
Changing the Primary Care Payment System to Promote Quality
I also believe we must change how primary care is paid for. The current fee-for-service system, which compensates primary care providers at lower rates than other providers for the same or similar services, is causing a severe strain on our existing primary care practices. Fee-for-service systems are disincentivizing med students and new doctors from joining primary care and place an emphasis on quantity of patient visits over quality. In tandem with increased investment in primary care, I believe that instituting a global payment system for primary care with a value-based component will decrease the burdens on primary care practices and increase the quality of care.
A global payment system is an agreement to pay providers a risk-adjusted fixed cost per patient over a fixed time period. Rather than getting paid retrospectively based on the quantity of in-person visits, like most current systems are based on, provider practices would prospectively receive a fixed amount of revenue for patient care services. This payment system decreases the uncertainty facing primary care providers over future revenue, de-emphasizes quantity of visits, and would vastly decrease the administrative billing burden. The stable revenue allows providers and practices to make investments in improved care and service delivery, and allows providers to be compensated for care activities they were already providing, like distance health consultations.
A global capitation payment system also invests providers in improving quality of care, because they share the risk of poor care and poor health outcomes. Payers can offer a value or performance-based component, which pays providers based on population health outcomes, and provides an additional layer of accountability for providers. There is strong evidence that global payment systems produce cost-savings through improvements to care quality, both in Medicaid and Medicare and among private payers. The revenue stability of global payment systems, in addition to reducing costs, opens the opportunity for providers to address some of the social determinants of health, like food and housing insecurity.
Applying a primary-care-for-all framework could also improve outcomes and cost savings for Medicare and Medicaid patients. Medicare spends even less on primary care than private insurers, averaging between 2.5-5% of overall expenditures. Medicaid is already experimenting with investing in and improving primary care in many states through its Primary Care First program that offers different payment model options to incentivize primary care services. In 2014, the Centers for Medicaid and Medicare Services struck a deal with Maryland to provide the option for hospitals to switch to global payment plans. All of the hospitals in the state signed up to replace fee-for-services plans. Within three years, Medicare saved an estimated $430 million in hospital costs, and an estimated $310 million in net savings after accounting for upticks in other types of care. Maryland saw quality improvements in health outcomes as well. Both Medicare and Medicaid recipients tend to have high rates of chronic diseases, suggesting that improving access to and delivery of primary care would have significant beneficial outcomes both in terms of overall health and cost.
Ensuring Universal Healthcare Coverage
Changing how much we invest in primary care and how primary care providers are compensated are necessary reforms to achieving a financially sustainable universal healthcare system that improves population health outcomes. These changes are not sufficient, however, to guarantee that everyone is able to afford health insurance. Particularly in underserved areas and rural communities, lack of insurer competition leads to higher costs, placing insurance out of reach for many families. This is why I support creating a robust public option for health insurance that will compete with private plans to reduce overall healthcare costs.
The public option must provide primary care for all, with no cost-sharing and no deductible. Americans will be able to access expanded, high-quality care directed by their primary care physician that includes internal medicine, pediatrics, mental and behavioral health services, reproductive healthcare, and eye and dental care. This system will emphasize accountable, coordinated, comprehensive, and continuous care to improve health outcomes and ultimately save on healthcare costs. The public option should utilize a global payment plan to ensure value and cost control, while stressing investment in primary care.
The public option must be accompanied by robust regulation to ensure a level-playing field between public and private insurers that leads to balanced risk-sharing. In particular, private insurers must be required to meet the same minimum threshold of investment in primary care and encouraged to adopt alternative payment systems to FFS, and they must cover the same basic primary care services at no cost to enrollees. We must also strengthen the non-discrimination provisions of the Affordable Care Act to ensure that patients with preexisting conditions are not shut out of private plans and forced onto the public option.
Reducing Drug Costs
A final and vital part of reducing healthcare costs involves allowing the government to negotiate drug prices with pharmaceutical manufacturers for public plans. Between 15 and 20% of total healthcare spending goes to prescription drugs. This is more than twice as much as we spend on all primary care services. No one should be forced to choose between paying for their prescriptions or paying their rent. Unfortunately, the cost of pharmaceutical drugs creates this dilemma for many and is another barrier to affordable care. Between drug plans under Medicare/Medicaid and a public option, we can negotiate with drug makers from a position of strength that will drastically reduce prices and help keep overall costs lower. I also support the House Democrats’ proposal to invest $10 billion in the National Institutes of Health for biomedical research to offset any loss to private research and development by pharmaceutical companies.
We have a fundamental duty to expand access to health insurance, achieve universal coverage, and to improve health outcomes. The research is clear that the most cost-effective and value-based services lie in primary care. This is why I support creating a system of universal Primary Care for All, supported by a public option and robust private regulation. We can have better healthcare in the United States, and we can do it for less.