December 12, 2016; Brookings Institution
The essence of the American healthcare system is again on the table as the new Republican administration and Congress are sworn in. The programs that have made healthcare accessible to millions of middle and low-income households face drastic modification by a leadership that views them as unaffordable and harmful government overreach and believes that a more market-based system can improve upon their effectiveness and efficiency.
While details of what will replace the Affordable Care Act after it is repealed and how Medicare and Medicaid will be restructured remain to be finalized, it seems certain that the impact of the changes will make it harder for those with the least resources to access the services they need. Policymakers may want to look at a recent working paper published by the Brookings Institution, “Money Lightens the Load,” before implementing changes to the healthcare status quo.
The current system has struggled to keep up with the economic changes that have broadened the gap between rich and poor:
Over the last few decades, economic inequality has increased, with strong growth at the top of the income distribution but slow growth in the middle and at the bottom. In recent years mortality rates among middle-aged Americans also have grown more unequal by income level…Health declines have been smaller for high-income individuals, resulting in an increasing gap in health between the lowest- and highest-income individuals.
Just days ago, we learned that life expectancy had fallen for the first time since 1993. According to NPR’s review of the data, “the overall death rate for Americans increased because mortality from heart disease and stroke increased after declining for years. Deaths were also up from Alzheimer’s disease, respiratory disease, kidney disease and diabetes…the decline was driven by increases in deaths from eight of the top 10 leading causes of death in the U.S.”
The Brookings paper’s authors based their conclusions on a number of key health indicators, including obesity and stress. They found significant differences between low-income, middle-income, and wealthy individuals. If the purpose of changing our current healthcare system is to improve its effectiveness for all Americans, then proposed changes can be measured against how they will affect a variety of factors that contribute to health outcomes.
Health disparities by income have a variety of possible explanations. Availability and quality of healthcare are well-documented factors that can improve health and decrease stress levels on the body. Income predicts differential exposure to external stressors themselves, both in the form of environmental hazards and financial and psychosocial demands. Chronic stressors such as food insecurity, substandard housing, and greater exposure to violence have also been demonstrated to increase the wear and tear on biological systems. Consequently, policies aimed at mitigating these problems for low-income families can help to improve health and families—for example, in the form of nutrition assistance—or assistance in relocation to neighborhoods that lead to better outcomes for low-income families. Policies that raise economic growth and maintain a strong labor market will benefit all Americans.
When Congress reconvenes and joins with President-elect Trump to work on making the healthcare changes they have promised, there are important questions to be answered if the goal is a system that improves our overall health. Will it make it harder or easier for all, irrespective of income, to get the care they need? Are the tax credits and health savings accounts being proposed as replacements for the ACA’s subsidies going to result in healthcare becoming more or less expensive? Will the new open-market insurance policies provide a greater or lesser level of coverage than those required under the ACA? Will block granting Medicaid result in improved access for the poorest citizens? What will change to Medicaid do to a system that seems to work well for so many?
And the most important question: Will time be taken to think carefully about the impact of change? Does anyone really care about how a new system will affect the lives of the poor and middle class?—Martin Levine