We can’t solve healthcare without an honest debate on government’s role

Marianne Udow-Phillips

Marianne Udow-Phillips is executive director of the Center for Healthcare Research & Transformation, a nonpartisan health policy center based at the University of Michigan. Its mission is to advance evidence-based care delivery, improve population health and expand access to care.

Efforts to repeal and replace the Affordable Care Act have swirled through Congress throughout 2017, culminating in the U.S. Senate’s 11th-hour failure to garner enough votes to advance its Graham-Cassidy bill before the end of the fiscal year.  It appears that repeal-and-replace efforts are now on “pause” as Congressional focus shifts to tax reform, providing time to reflect on the underlying issues that resulted in so much turmoil over the past nine months.

The health care debate exemplifies much of what is wrong in politics today: There is much talk about policy proposals and virtually no talk about the beliefs that underlie those proposals.

As Americans, what do we believe is the government’s role in ensuring access to health care? What do our elected policymakers believe?

Nearly every other developed nation answered these questions decades ago. From Germany’s Otto Von Bismarck in the 1880s and the British duo of Beveridge and Bevan in the 1940s, to Canada’s Tommy Douglas in the 1960s, leaders in countries that have adopted a comprehensive approach to health care have articulated the government’s role in financing health care.  

In all of these cases, the basic health care financing mechanisms have proven remarkably sturdy over time and well supported by the public at large.

In America, we have never really debated the core issue about who should pay for health care and why. Without that open and clear debate, health care financing in America continues to be controversial and the policy goals muddled.

While there was some allusion to beliefs on the government’s role in the most recent health care debates, those underlying beliefs for the most part became obscured with slogans about “freedom” or “death spirals” or “exploding markets” or “the collapse of Obamacare.”   

Broad and inaccurate statements, like “everyone already has access to health care,” further obscure the more important belief debate. These statements generalize the fact that, by law, hospital emergency rooms cannot turn people away regardless of their health insurance status. However, that limited, legally-mandated “access” is not what most people mean when discussing the government’s role in helping to assure cost is not a barrier to care.

The core question then becomes: Is it government’s role to ensure that people have access to a set of defined and relatively broad health services regardless of cost?

By reverse engineering, one can see the dueling belief systems at work in both the House-passed ACA repeal and replace bill, the American Health Care Act (AHCA), and the most fully developed Senate ideas embodied in the Better Care Reconciliation Act (BCRA) and Graham-Cassidy bill: one treats health care as any other good or product in the marketplace, while that the other treats health care as a social good.

The market viewpoint is reflected in many provisions within these bills. In particular: the ability of states under certain conditions to waive requirements related to essential benefits and allow rates to vary based on someone’s health status. Provisions that would repeal the cost-sharing subsidies, end the Medicaid expansion enhanced funding and limit core Medicaid funding through per capita caps or block grants also support the viewpoint that government’s role should be limited when it comes to health care financing.

The social good viewpoint—that people should have access to at least some critical health care without financial barriers and regardless of health status—is also embedded in these bills. This viewpoint is visible in provisions that continue to provide individuals with tax credits to purchase health insurance coverage and that provide states with additional funds for high-risk pools, reinsurance (invisible risk-sharing) and special funds designated to cover maternity care, mental health and newborn care.

The contradictory philosophies that underlie these differing policies are what made it so difficult to get a bill through the House and the Senate: They offer two competing views on the role of government in health care.

Most of the obfuscation about goals is coming from those who believe healthcare should be treated and priced as a market good. That belief system is a legitimate viewpoint that should be articulated and debated. Yet champions of this market good perspective have not been explicit largely because it is out of step with the American public. In a January 2017 poll, 60 percent of Americans said the government has a responsibility for assuring healthcare for all.

The overarching role of government in health care financing is a settled question in all developed countries except the United States. For citizens to effectively engage in a policy debate, they must understand what philosophy their representatives are trying to achieve. Only with that clarity can true bipartisan solutions be pursued between those who share differing belief systems.

If the policy goals are aligned, then the health care coverage issue becomes a technical question of what works and what doesn’t, which evidence can inform. However, that technical issue can only be productively addressed once it is clear that policy makers are working toward the same goals.

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Carl Ver Beek
Thu, 11/02/2017 - 10:19am

This is a good explanation of the problem but it does not address a process for a solution.
Unfortunately, many who favor government action on an issue seem to assume that by identifying a problem their solution is mandated.
We not only don't have consensus on the role of government , we lack consensus on the scope of any health care which government should provide.
Those who see health care as an entitlement make a discussion of the scope of care very difficult, as they tend to be absolutists who say everyone is entitled to the same level of care, regardless of ability to pay.
We do not see food, clothing or shelter in the same absolutist terms, even though they are necessities of life.
Why is health care different?

Robyn Tonkin
Thu, 11/02/2017 - 12:16pm

I think it should be obvious to you why healthcare is different, and I hope you can begin to see life as the grey-area, nuanced thing it really is. If you get most of your news, and hence your opinions and views from right wing tv shows, bloggers and op-ed pieces, shut all that stuff off, quit looking at it and quit reading it, and think for yourself, alone. I may be liberal, but I can't stand reading or viewing the stuff because they have no more nuance than the right wing stuff does.

What are clothes, shoes and a place to live? Inanimate, material objects. What are you? What is the person in the next cubicle? What is the person at the next restaurant table? You and all the strangers you have close encounters with each and every day are live organisms. All harbor germs within their bodies, and contract and transmit illnesses and diseases. If someone is unhealthy-- overweight, malnourished (how many corn products do you ingest each day instead of animal protein) and low on essential nutrients, as they age, they will begin to exhibit signs of the Deadly Quartet--heart disease, fatty liver, diabetes and atherosclerosis. They will start to need more and more drugs to maintain a semblance of homeostasis, and be more and more of a health burden. If they have no health insurance, they will go to the ER and get care there, and that cost will be passed on to the rest of the people who can pay. If someone gets no health care at all, and goes about in society after contracting tuberculosis, AIDS, one of the suite of hepatitis diseases, or another infectious disease, they have strong potential to give it to other people. If you get on public transportation, or walk down a city street, how do you know if the person you are sitting next to or passing has TB and is going to sneeze or cough on you? You don't. But if universal health care were available, a sick person would have more options to being seen by a doctor when they began to feel unwell.

We need universal health care because we are organisms living in a crowded society. Each person's access to healthcare has the potential to increase the health of the population. Each child having access to healthcare, each pregnant mother having access to adequate prenatal care, and each family having access to wellness information and care, aids in producing a healthier, smarter and more active next generation which leads to a more robust overall population.

Southern California right now has an outbreak of Hepatitis A caused directly by lack of toilets for the huge homeless population to defecate in. During the day, they are turned out of shelters, and toilet facilities and hand washing opportunities are profoundly inadequate or completely lacking, in the parks, parking lots and open spaces in which they congregate. They relieve themselves where they can, probably without benefit of toilet paper or paper towels, not to mention soap and water for handwashing. Then, the inevitable happens in a crowded environment, and the germs on someone's hands get transmitted inter-personally, and the disease goes from invisible in the population, to outbreak. We can ignore the homeless, ignore basic hygiene and sanitation, which are integral parts of healthcare, in a discipline known as "public health" and in return we get dangerous surges in potentially fatal diseases. The CDC has shipped 81000 doses of Hepatitis A vaccine to Southern California, all of the doses they had of what is admittedly a rare vaccine.

So you see, we need universal healthcare, for the health and safety of all of us. It is not at all like picking out a new shirt online.

Mon, 11/06/2017 - 8:11pm

I am disappointed you start by assuming who thinks for Carl when you describe where he gets his information. I listen to a wide range of media [I have stop watching MSNBC], and I have found the media segregates their coverage never tying the political coverage of Obamacare, Medicare/Medicaid, medical insurance coverage to the health and contributing factors to medical care demand. If you are building your approach to the issue by only what the media provides, no matter the source, I think you might what to look where your other three fingers are pointing when you point the one finger at where you think Carl is getting his information. When it comes to medical care/personal health, I have been listening to doctors/nurses/other health professionals [including my own] for years and they have always included lifestyle as predominate factor in personal health and medical care needs. With that information seems it isn't only about someone else paying for everyone's medical cares, it includes personal responsibility and choices.

What is needed is a well-defined question/problem/issue, so we don't talk pass each other by using our own definition and letting others use theirs. Is the question of unlimited on demand medical care or is it personal health? You tell me what the question is then I will offer ideas and you comment, I will listen, respond, and we will have a conversation.

Susan Robertson
Thu, 11/02/2017 - 12:21pm

Interesting comment. Why don't ACA's essential services and pre-X provisions define the scope of care? I'm not sure I understand your comparison. It seems to me that we DO see food, clothing and shelter in the same terms, i.e. social safety net programs funded by the government - SNAP benefits, public housing, Public Education, Medicaid, CHIP, free vaccination services through Public Health Services - all basic necessities, and always, ALWAYS in contention.

Thu, 11/02/2017 - 12:35pm

I respectfully disagree with Mr. Ver Beek's evaluation of this article. The first step to a solution IS to identify the problem, which Ms. Udow-Phillips does very well. Her solution is, if not spelled out as a bullet list of proposed actions, obviously suggested by what she writes: for everyone, especially politicians and policy-makers, to clarify (for themselves and their constituents) what their philosophy and policy goals are BEFORE arguing about how best to implement them. I also disagree with Mr. Ver Beek's statement that "those who see health care as an entitlement . . . tend to be absolutists who say everyone is entitled to the same level of care, regardless of ability to pay." I discuss health care solutions with many people who share my view that the government should - and not out of moral concerns, but practical ones - provide at least a minimum level of health care to all residents of the US. None of these people is an absolutist such as you describe; they are pragmatists and would be perfectly fine with a system that provided basic health care while allowing people to purchase higher/different coverage health insurance for non-essential care.

And finally, you assume that "we" do not see access to food, clothing, or shelter in the same "absolutist" terms, implying that it would not be reasonable to do so. First, people have some choice in how much expense they incur for those items: food, clothing, and shelter, while more expensive than some can afford, generally do not carry the price tag of many medical procedures. I can choose to buy a $15 t-shirt or a $400 designer sweater - I am not constrained by a medical problem to purchase the latter. Second, many people (and again, this is purely anecdotal, since I have no statistics and am relying on my conversations with others about this) do actually feel that one of the roles of government is to provide a safety net for its citizens, whether in the form of unemployment income, homeless shelters, or other forms of assistance. Health care is not different; it is just the issue that is currently on the table.

John Saari
Sun, 11/05/2017 - 8:23am

Lots of political talk, nothing getting accomplished. Ignoring successful ventures. Reinventing the wheel. Fixing what is not broken. Squeaky wheel getting too much attention. Political representatives should be able to be voted out easily.

John Saari
Sun, 11/05/2017 - 8:29am

Food, clothing, housing as well as healthcare are necessities of life. For a civilized society, a job and an education is also provided. Levels of all these things must be affordable

Thu, 11/02/2017 - 12:46pm

"The core question then becomes: Is it government’s role to ensure that people have access to a set of defined and relatively broad health services regardless of cost?"

Here in America, the answer is clear (if one bothers to look); it is a very obvious and resounding "NO".

The powers of the federal government are clear and defined. The people who wrote the Constitution even said so themselves.

If anyone cares to test this theory, I would recommend that they contact their elected official (especially if they are one of those who are still promoting and defending Obamacare), and ask them to cite the relevant portion in our Constitution to back up their belief that this actually is an enumerated power of the federal government.

Good luck waiting for a response.

I haven't received one yet even after over ten years of asking.

Now, just to warn people, some politicians will pull their answers out of thin air, hoping that were simply too stupid to know any better.

Rep. Conyers attempted this trick several years ago with predictable results.


And if Ms. Phillips wants to cite what other countries are doing relating to government ran health care, at the very least, she should have the integrity to include what they aren't doing as well.

Things like the time that you'll be spending waiting for treatment.


Did you think that waiting times for an ambulance in Detroit were bad? See what happens when you're waiting in one under a government ran health care system.


And if you think that you can just get up and leave (to of all places America)? Well, think again. The government will essentially kidnap your baby and not let you leave that country for treatment. Adding insult to literal injury, they won't even afford you any dignity during your final hours.


And this is but a few examples of what people like Ms. Phillips want to see here in America.

If anyone believes as she does that this is a settled question, then I have a bridge (no pun intended) and some prime Florida real estate that you will be interested in as well.

Kevin Grand
Thu, 11/02/2017 - 4:16pm

That comment above was from me.

Mon, 11/06/2017 - 2:49pm

The constitution says the role of government is to prone the general welfare. So we should by feeding, housing and caring for the health needs of our people. That is Explicitly what it says

Thu, 11/02/2017 - 1:13pm

Americans want only a few things; everything to do with their physical bodies to be perfect no matter how old or what choices they make or made. No pain or discomfort to any recognizable threshold. Access to any and every treatment no matter how expensive, unlikely the benefit or condition of the recipient. AND LASTLY, SOMEONE ELSE TO PAY THE BILL! Politicians are unwilling to say no or are actively encouraging this for their political advantage - it's a right after all!
The Federal government already pays for at least half of all medial care so to a large extent we already have single payer. There is almost no free market in medicine, defined as individuals choosing and paying for their own desired care. So whether the government or insurance companies pay, we have a cost shifting system with all the predictable results. From there you pile on a one size fits all federal programs with its unlimited(?) ability and appetite for unlimited borrowing, our grand children and great grand children will be paying for our care for ever! The only way out of this is to pass publicly provided/funded medicine onto the states, with the funding (at some limits, unless the states want pony up additional funds) with full flexibility and authority to fully design their own systems as they see fit and can or willing to afford. Then let individuals choose to go into either this public or a private system with no mixing. This isn't that different from Canada's approach using the provinces to handle healthcare.

Barry Visel
Thu, 11/02/2017 - 3:03pm

I think I could buy in to single pay system for health care (those that know me are gasping right now). BUT, two things need to happen before I’ll believe the Federal government has a role. 1. The Constitution needs to be amended to provide authority for the Feds to get involved. (If anyone thinks that authority already exists, please provide me the authorizing language from the Constitution, or from any amendments). This is where the debate should begin, i.e, a constitutional amendment. 2. We must address the much higher per capital health care costs and relatively lower life expectancy we enjoy(?) in the U,S. I don’t see either of these issues being addressed in the current conversation.

John Saari
Sun, 11/05/2017 - 8:17am

When a representative government fails (to provide healthcare) the people should be asked to vote on what they want. Choose between the top 10 successful companies.

John S.
Sun, 11/05/2017 - 6:06pm

Politicians are very careful to construct narratives or stories that rationalize their underlying values and also appeal to campaign contributors, party activists, and voters. Often, there's little or no evidence to support such stories. They are inclined to ignore the sound advice of experts , like the author, if there's no political gain in it for them. Cynically, after all else fails, they occasionally get around to doing the right thing. This cynic would argue that there is far too much health care in this country and not enough health. Examples: hospital acquired infections, the overuse and misuse antibiotics, unnecessary surgeries, botched surgeries, unnecessary diagnostic procedures, industry capture of the FDA, the opioid epidemic, pill mills, futile and costly end of life care, etc.

Chuck Fellows
Wed, 11/08/2017 - 7:13am

One Issue: Fee for service. Goal becomes number of patients seen, division of health care services into discreet specialties, patient turnover. Outcome, high cost low quality when compared to non fee for service providers (Mayo/Cleveland/Kaiser/ROW).
That is an issue that the health care industry could address on its own but chooses not to. Reason - greed & power.
Rest of developed world provides better care at lower cost. United States is being left behind and becoming more non competitive every day, not to mention shorter life spans.
Besides, we already have government provided payment for 80% of the nations health insurance - the tax credit to corporations for providing employee health care - taxpayers pay, not the corporation or the employee. That "system" has produced an inefficient and unsustainable health care marketplace, no one is accountable for cost or quality.

Marj Pedigo
Sat, 01/20/2018 - 2:30pm

Two quality of life essentials should never be for profit:. Healthcare and education. The discussion should start from that premise.