From a strategic perspective there are three broad areas of health care policy:
First is the set of policies addressing health insurance and access to insurance: who has health insurance, how health plans operate, and how insurance is paid for. Many countries have addressed this issue with a government-run system that provides insurance for all. We believe that everyone must have a health plan, but that there are better ways to achieve universal coverage than a single-payer system, as we shall discuss.
Health insurance draws the majority of policy attention in the United States. As health insurance has become more and more expensive, individuals are being asked to pay more toward their coverage. As the number of uninsured grows, the debate about access and the structure of insurance is taking on ever more urgency. Recently, much attention has been focused on enabling health savings accounts. These are the front-line issues in health policy.
Enact mandatory health coverage
Provide subsidies or vouchers for low-income individuals and families
Create risk pools for high-risk individuals
Enable affordable insurance plans
Minimize distortions from uneven employer contributions
Eliminate unproductive insurance rules and billing practices
A second broad issue in health care policy is coverage: what services insurers and society should be responsible for covering and what services individuals should pay for themselves. This includes difficult issues surrounding the extent of treatment that is justified in terms of its health value (for example, treatment near the end of life), the types of care that should be discretionary (for example, fertility treatment), and the responsibilities of patients in participating in their health and their health care (for example, should subscribers who refuse to participate in health risk screening pay more for their health care?).
What is covered by insurance is a major determinant of the costs of public and private plans. Historically, states have weighed in on this issue through mandating the services that must be covered in private health plans, while Congress plays a big role in what is covered by Medicare. The tendency toward too many mandates has significantly increased the cost of insurance and expanded the number of uninsured.
Establish a national standard for minimum required coverage
Consider medical outcomes and patient preferences in covering end-of-life care
Introduce individual accountability for participation in health care
The third broad issue in health care policy is the structure of health care delivery itself. It is the delivery of health care that actually creates value for patients, but this area has received less attention until recently because U.S. health care was assumed to be uniformly good. The result was more and more public and private money poured into health care with little attention to the value delivered.
The policy attention directed at health care delivery has been dominated by how to reduce cost—for example, requiring Certificates of Need for new facilities, preventing self-referral to doctor-owned facilities, ensuring the lowest prices for Medicare, buying drugs from Canada. More recently, attention has been focused on the importance of information technology and pay-for-performance initiatives to reduce errors and improve quality. These are welcome steps, but their focus is still largely on attempting to control the supply of care and bargain down prices, rather than on enabling competition in terms of value.
Enable universal results information
Improve pricing practices
Open up competition at the right level
Establish standards and rules that enable information technology and information sharing
Reform the malpractice system
Redesign Medicare policies and practices
Align Medicaid with Medicare
Invest in medical and clinical research