An American Health Service?
A progressive idea that could win conservative support.
While I reject the premise that Joe Biden needs to move left to court disappointed supporters of Bernie Sanders, Jordan Weissman’s actual policy proposal in “Here’s How Biden Should Move Left on Health Care and Court Sanders Voters” is worth considering.
Biden should propose creating an American Health Service, an expansive network of federally funded, locally run primary care providers and hospitals that would offer more affordable treatment and help coordinate public health responses. It would build on the thousands of community health centers that already serve low-income and rural communities, which Sanders played a key role in growing, but cater to middle-class patients, as well. And it would all come wrapped in some stirring patriotic branding.
Given the long setup, I was prepared to simply dismiss this as a classic case of “this situation calls for enacting my pre-existing policy preference. But he makes a good argument.
Why an American Health Service? First, and most important, it would be good idea on the merits that would address some of the glaring shortcomings of our current medical system. Most discussions about health care reform in this country tend to focus on the insurance side of the equation, for the obvious reason that we’re the only advanced country in the world that doesn’t have universal coverage. But many corners of the U.S. suffer from a basic lack of health care services, too. More than 77 million Americans live in federally designated Health Professional Shortage Areas, where providers are in short supply for part or all of the community; the dearth is especially acute in poor and rural areas, which leads people to rely on expensive emergency rooms for essential care.
The U.S. also fares poorly in international measures of health care capacity. Despite spending a bigger share of our economy on health care than anyone else, we have far fewer doctors, hospitals, and hospital beds per capita than many of our peer nations. Meanwhile, we’ve got a rural hospital closure crisis that’s threatening to make these issues worse. We overspend, yet we’re under-resourced. And while it’s too hard for many Americans find a doctor even in normal times, now we’re fighting a plague that has left us all worried about literally running out of hospital rooms.
One straightforward way to address these shortages would be to publicly fund more providers, the tried and true method used across much of the globe. In the U.S., public hospitals provide just 15 percent of beds, according to the Commonwealth Fund. In Australia and France, by contrast, they provide about two-thirds; in Germany they provide almost half; and in even in heavily privatized Japan, they provide more than 20 percent. I’m not exactly suggesting that we try to replicate the United Kingdom’s National Health Service, which directly employs most of the country’s doctors and cares for the vast majority of patients. But if we want hospitals to survive in, say, rural Oklahoma, it seems like we should take a cue from our international peers and just pay for hospitals in rural Oklahoma.
Indeed, one of the criticisms of Medicare for All was that, while it would ensure that all Americans would be able to pay for healthcare, it did nothing to ensure they had access to it. Given how expensive they are, the private sector simply isn’t going to build hospitals in sparsely populated areas.
And, yes, the current crisis demonstrates the value of surge capacity. And, again, the market is unlikely to provide it, given that empty hospital beds and unused equipment are very expensive to maintain.
Is building publicly-funded hospitals in rural areas “socialism”? Sure. But no more so than building publicly-funded hospitals for veterans. Nor is it unprecedented otherwise in our system.
We also already have a successful model to work from: Community Health Centers, which provide primary care and services like mental health, dental, and drug treatment to around 29 million patients across the country. For that, we can largely thank Sanders, who convinced Democratic leaders to ramp up federal health center funding during the negotiations to pass Obamacare. These clinics receive federal grants, along with state and local dollars, to treat residents in underserved communities and charge on a sliding scale based on income (people in poverty pay little or nothing). Almost half their patients use Medicaid, while another 23 percent are uninsured, according to the National Association of Community Health Centers. These are not, for the most part, government-run operations—the vast majority are private nonprofits. But they have to abide by strict operating and reporting rules, including a requirement that patient representatives make up the majority of their governing boards, which keeps them focused on their public mission. And research suggests that they are very successful at providing high-quality care to patients while also lowering costs.
I’m only vaguely familiar with the program but it seems like a reasonable system. Then again, I went to Army doctors from infancy to my mid-20s.
And it turns out they’re pretty cheap, to boot.
Sanders is widely seen as the patron saint of the Community Health Center program, and he has proposed boosting its funding as part of a wide-ranging effort to increase access to primary care in the U.S. But the centers are now widely popular within the Democratic Party; Hillary Clinton wanted to expand them in 2016. Joe Biden is currently calling to double their funding, which reached $5.6 billion in 2019.
But why not go bigger? An American Health Service could include the more than 1,300 Community Health Center organizations that already exist, which ran 11,744 care sites in 2018. Biden could triple or quadruple their funding over time, with the goal of expanding the number and size of clinics, while providing subsidized services to more middle-class patients. He could then take the basic health center grant model and apply a version of it to hospitals in underserved areas. Last July, Sanders proposed a large bailout fund to help states and counties buy distressed local hospitals. Biden could do him one better by a creating a continuous source of funding, with strings requiring hospitals that participate to keep charges affordable and serve needy populations. Nonprofit and public hospitals could both apply. And there could be additional funding for states to build new hospitals (or reopen old ones) in areas that currently lack enough beds.
Weissmann argues that it would be good politics, too:
Aside from being good policy, creating an American Health Service would probably be a popular idea that would fit with Joe Biden’s moderate image. Americans don’t love being told to give up their private insurance. But they do like public (or quasi-public) services. The Community Health Center program in particular enjoys overwhelming support from Democrats, as well as significant backing from Republicans, who understand that it’s a crucial source of care for their rural constituents. When its funding lapsed in 2018, 105 House GOP members signed a letter to then-Speaker Paul Ryan urging him to reauthorize it. Slapping a catchy name on the program and supersizing it to include more clinics and hospitals is an idea that moderate Democrats should be able to get behind. It would also cost a fraction of other ambitious health policy ideas. Again, the current Community Health Center program costs about $5.6 billion per year. You could go an order of magnitude higher and it’d still look modest compared to the policy ideas that have been kicked around this campaign cycle; plus, it could save money for programs like Medicaid by reducing patient costs.
Again, I don’t have the expertise to know whether this would work on a larger scale. But $5.6 billion is a tiny chunk of change in a $4.7 trillion budget.
I don’t know that running on this plan would make that much of a difference in winning Sanders supporters or swing voters. But this actually is a time when the current crisis demonstrates the need for a pre-existing preference.