Massachusetts, the first state that attempted to offer health care to all its residents and provided the template for national health reform, recently took the inevitable and much more difficult next step.
It passed a law intended to restrain future growth in total statewide health care costs. Once government has adopted a policy of achieving universal health care, it must then take steps to maintain affordability.
For the past 50 years, our national health care policy has been one of relentlessly expanding our system’s capacity. In the mid-1950s, the Internal Revenue Service made employer-provided health benefits tax exempt. In 1965, building on the legacies of Presidents Roosevelt, Truman and Kennedy, President Johnson prodded the Congress into enacting Medicare and Medicaid, thereby infusing billions of public dollars into our health care system for direct care of the poor and elderly.
During the following decades, under both Democratic and Republican administrations, Congress further expanded our health care system, creating community health and mental health centers, the national health service corps and expanding health benefits for federal workers, the military and their dependents, as well as veterans and Native Americans.
Congress also provided support to increase the numbers of doctors, nurses and other health care professionals and to construct hospitals and other health care facilities. Federal support for basic biomedical research was massively expanded through the National Institutes of Health.
That support subsequently spurred unprecedented innovation through the conversion of publicly funded scientific knowledge into commercially viable products and the capability to use them. With the help of sophisticated marketing techniques, these products and services are now being relentlessly promoted in an effort to increase demand.
So our public policy regarding health care has been to spend trillions of dollars to expand our capacity to provide services, personnel, facilities and innovation. These efforts have been hugely successful. Per-capita health care spending (in constant dollars) has increased by about six times since 1966, when Medicare was implemented, and we’re now at about twice the spending level of other wealthy countries.
But despite our high spending, we have the highest percentage of population without adequate access to health care, the poorest health outcomes and the least popular health care system of any advanced country.
The return on our public investment in health care has been disappointing. It is as though we have written a blank check to develop the world’s most powerful and technically sophisticated car, but now find it accelerating out of control, guzzling fuel at an unsustainable rate and lacking any controls.
We have been counseled by the experts to do everything we can to improve efficiency and reduce the demand for services by forcing people to become healthier; better managing treatment; reducing waste, fraud and abuse; increasing competition; making health care more “consumer directed” by requiring patients to pay more up front; and improving efficiency through more and better technology.
None of these ideas is new. All have been tried and, by themselves, failed.
If we look at evidence for what works from around the world, the results are clear. All other countries have been more successful than the U.S. at restraining costs and improving results. They have done so by constraining overall system capacity and managing the flow of health care facilities, personnel, technology and money into their systems. They have achieved better results at far less cost.
That is why the new Massachusetts law is so intriguing and so critically important. Despite the huge contribution of health care to that state’s economy, the Massachusetts Legislature has shown the political will to cap capacity and slow the growth of their total health care spending even as they are trying to increase access. Failure to do so threatens their goal of health care for all.
Of course, dramatically simplifying our byzantine and archaic system by replacing it with “Improved Medicare for All” on a state or national level would make this task much easier and would create a way to implement a health care budget that treats everyone fairly. If everybody has a stake in the same system, popular support to better manage and more effectively control its costs would be much stronger. That’s the way it works in most other countries.
Instead of fighting over who gets what, we would all support improvements in a system that benefits us all.
Winston Churchill once observed that “Americans will always do the right thing, once they’ve exhausted all alternatives.” Despite its flawed approach, Massachusetts now leads the way in its attempts to simultaneously improve access and control costs.
In contrast is Maine, which, with the insurance companies firmly in control of our legislature, is going backwards. Working together, people in Maine could change that.
Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at firstname.lastname@example.org.