I’m haunted by the stories of two women.
The first is Andrea.
Andrea is a stay-at-home mom of 3 small children
when she was diagnosed with breast cancer at age 36.
Fortunately, her husbund’s in a good health insurance.
So she was able to get the preventive care she needed,
But when symptoms persisted, genetic testing revealed
she carried the gene for breast and ovarian cancer,
despite no family history of cancer.
A 1 in 800 chance.
She was then able to get additional protective surgery,
including the removal of her breasts and reproductive organs.
The second is Verda.
Verda was a single mom of two children
when she felt a lump in her breast at age 38.
A state-sponsored screening program revealed it to be cancerous,
and her state-funded health insurance paid for its removal.
But shortly thereafter she lost that insurance.
Several years later, while working as a waitress witn no health insurance,
几年后 在她做服务员 仍无医保时
she felt a pain in her chest.
Despite her history, she decided not to go to the oncologist.
Cuz she was afraid she couldn’t pay his(her) bill.
By the time she went to the ER with dizziness,
the cancer metastasized throughout her body.
The first woman, Andrea, is my beautiful wife.
Today, she’s healthy and cancer-free.
The second woman, Verda Wells, a Springfield Illinois,
died on July 2nd 2009, shortly after that ER visit.
Both women got the same diagnosis, at roughly the same time,
and both lived in the richest nation on Earth.
But they also lived in the only wealthy country
that doesn’t guarantee health insurance for all.
The result is enormous disparities in financial protection and health outcomes,
as illustrated by my wife’s story and that of Verda.
This isn’t just about stories, but also hard facts.
A white baby born in America today
has the same chance of seeing their first birthday as one born in Europe.
While a black baby has a lower chance than one born in Libya.
The Roland Park neighborhood of Baltimore
has a life expectancy of 84 years, higher than the national average.
While 3 miles away,
the Sandtown neighborhood has a life expectancy of 67,
lower than that of North Korea.
Before the Affordable Care Act came along,
80% of Americans had quality health insurance, like my wife and I,
through their employer or through government programs
like Medicare or Medicaid.
For some, this insurance was far from ideal,
as it featured high costs and a limited choice of providers.
But overall, this was substantive coverage
which enrollees were by and large satisfied.
On the other hand,
the other 20% of Americans were either uninsured
or faced the prospect of buying insurance
in the unstable and discriminatory non-group insurance market.
This is a market where it was totally legal
for insurers to discriminate against the sick for any reason.
Insurers could deny the sick coverage;
they could charge them much more than the healthy for insurance
or they could exclude their pre-existing illnesses from coverage.
As a result, if you were healthy, you could get health insurance.
结果是 如果你健康 就能得到医保
But if you were sick, like Verda, you are out of luck.
This defeats the whole notion of health insurance.
Health insurance is supposed to protect you against financial risk,
not protect your insurance company against the sick.
And as a result, people in this market
were just one bad gene or one bad traffic accident away from bankruptcy.
Now, if you’re part of the fortunate 80%,
like my wife and I, why should you care?
I would argue you should care for 3 reasons.
The first is risk.
Unless you have a tenure job with lifetime employment,
you are always at risk of losing your Employer Sponsored Insurance, indeed.
In the decade before the Affordable Care Act passed,
10 million Americans lost their Employer Sponsored Insurance.
That’s 10 million people who thought they were financially secure,
only to face the risk of devastating medical spending.
The second is cost.
The uninsured actually impose a high cost on the insured.
Under US law, hospitals must treat anyone who comes to the emergency room
regardless of insurance status.
When the uninsured are unable to pay their bills,
this becomes uncompensated care,
a 50-billion-dollar-a-year cost
that’s passed on to the insured in the form of higher bills.
The third is economic efficiency.
The very lack of universal coverage lowers the efficiency of the US economy.
Individuals with health insurance on their job
are afraid to leave those jobs for fear of losing that insurance.
An economic research has shown
that many individuals are unwilling to move on to productive new jobs
or to start new businesses because of these fears.
Given that mobility is the lifeblood of the US labor force,
this hurts all of us by shrinking the size of our economy.
Now, Americans have had a long-standing interest
in fixing our broken insurance markets.
But here we run into a problem—
you can’t just legislate the removal of insurer discrimination in a vacuum.
Indeed, 7 states tried in the 1990s,
确实 20世纪90年代 7个州曾尝试
banning the ability of insurers to discriminate in their non-group insurance markets.
And in all 7 states, the same thing happened.
Insurers were worried that if they couldn’t discriminate against the sick,
they’d be swamped by sick enrollees and lose money.
So insurers either fled the market, or raise prices through the roof,
cratering the non-group insurance market in all 7 states.
One of these states was my home state of Massachusetts,
and our non-group insurance market was a disaster.
Then our governor, and future Republican presidential nominee
之后 我们州长 即后来的共和党总统候选人
Mitt Romney had an interesting idea.
Romney thought it was unfair
that the insured could avoid buying insurance
and yet get healthcare for free when they were sick at the emergency room.
Romney’s idea was to mandate that everyone buy insurance
so the healthy pay their fair share,
And so the insurers, don’t get…get to…just get stuck with sick enrollees.
And to make that mandate affordable, Romney proposed subsidies
to offset the cost of health insurance for low-income individuals.
Governor Romney asked me to use economic modeling to assess
whether such a plan was viable and affordable for the state.
I found that it was.
And I’m proud to say,
this played a key role in the passage of our state’s healthcare reform
in the spring of 2006.
Romney’s three-legged stool, banning insurer discrimination,
an individual mandate and generous insurance subsidies
became the basis for Massachusetts’
first-in-the-nation universal health insurance coverage law.
The uninsurance rate in Massachusetts fell to 3%,
compared to 18% nationwide.
And premiums in our non-group insurance market
fell by 50% relative to the rest of the country.
Meanwhile, there were no negative effects on the vast majority of state residents
that already had quality health insurance.
Indeed, this law was so successful,
it became the basis, 4 years later, for the federal Affordable Care Act.
Once again, Presiden Obama and the US Congress
asked me to use economic modeling to assess
whether the Massachusetts’ Three-Legged Stool model
could work for the nation as a whole.
The first leg was a ban,
for the first time in our nation’s history,
on the ability of insurers to discriminate.
No longer can insurers deny coverage to the sick,
charge women more than men for health insurance,
or exclude asthmatics or cancer survivors from coverage.
The second was an individual mandate,
albeit with exemptions for low-income individuals
and those whose insurance is too expensive.
The third was a two-pronged approach to health insurance affordability
an expansion of the low-income Medicaid program for our poorest citizens,
and the introduction of generous tax credits
to offset the cost of health insurance
in the new state ACA exchanges for the lower middle class.
I found that such a plan could work for the country,
and work it did.
Within 2 years of implementation in 2014,
20 million Americans have gained health insurance coverage.
Economic research has shown that because of the ACA,
the uninsured faced reduced financial distress,
were more likely to have a regular source of care
and got more of the preventive care they needed.
Indeed, recent studies have found that
tens of thousands of lives were saved by the ACA.
Meanwhile, premiums on the new state exchanges were below projections
leading the cost of the law to be well under budget.
And predictions of negative effects proved unfounded,
as employment growth in the US continued unabated,
and Employer Sponsored Insurance premiums grew at their slowest rate in measured history.
But while the ACA was a policy success,
it was a near-term political failure.
Partly this reflects the fact the law wasn’t implemented until 2014,
4 years after its passage.
This gave opponents 4 years to vilify the law in theory,
while supporters had no tangible benefits to point to in practice.
Then, when implementation of the law was hounded by technical failures,
it strengthened the narrative that the law wasn’t working,
even though those failures were fixed within a few months.
The ACA was an early success
delivering coverage to millions at below budgetary cost,
but these successes could not break through the noise,
and the supporters of the ACA suffered enormous political losses.
By 2017, with a new president and a new congressional majority,
到2017年 新总统上任 国会多数党易主
who had campaigned on repealing the ACA,
and things look dire for the law.
But then, a funny thing happened.
The law had been in place for a few years,
and folks started to appreciate its benefit.
Many individuals had benifited from the ACA,
and then, who wanna see those benefits go away?
Meanwhile, opponents could not deliver on an alternative
that did not result in tens of millions of Americans losing insurance coverage,
and the reintroduction of pernicious insurance market discrimination.
As a result, by 2017,
public support for the ACA crossed 50% for the first time,
and the efforts of repeal failed.
So, where does the ACA stand today?
It’s still the law of the land, and it’s largely working as intended.
But the battle over repeal weakened the law,
in particular, through the removal of the individual mandate,
and the erosion of insurance market protections.
As a result, 2 to 3 million Americans lost health insurance coverage,
and premiums on the state exchanges risen rapidly,
because we no longer insure the participation by the healthiest individuals.
Fortunately, there’re changes we can make to strengthen the ACA.
Some are relatively modest.
While the ACA features tax credits
to offset the cost of health insurance for low-income families,
too many Americans continue to find health insurance unaffordable.
An expansion of those tax credits could make health insurance attainable
for low-income families struggling to make ends meet.
Some problems are more fundamental.
Perhaps the biggest failure of implementation of the Affordable Care Act
was the rejection by some states of the Medicaid expansions.
Medicaid is a state-run program,
but under the ACA, the federal government agreed to pay
90 to 100 percent of the costs of covering all the poor.
An incredibly good deal for states.
Yet, due to political opposition, a number of states turned this down.
This means women like Verda, could have had life-saving health insurance
这意味着 不用各州花钱 Verda这样的女性
at virtually no cost to the state.
But politics got in the way.
Another problem is the lack of competition on the state ACA exchanges.
In many areas, these exchanges feature only one or two insurers,
resulting in very high premiums.
One approach to addressing these issues is the public option.
The idea is quite simple.
Let’s make private insurers compete with a new government-run plan,
like Expanded Medicare.
Low-income citizens in states that didn’t expand Medicaid
could then enroll in this new plan,
bringring millions into coverage.
And it’ll provide robust competition for private insurers
on the exchanges, bringing down premiums.
But even this approach faces some limitations.
Millions of Americans like Verda will continue to fall through the insurance cracks
because of issues of life transitions or affordability.
And more broadly,
our fragmented multi-payer private health insurance system
features high and wasteful administrative spending.
An approach to address these shortcomings
would be to move to a single-payer healthcare system,
where all private health insurance is replaced
with a single free government-run plan.
Americans will be enrolled in this plan from birth,
insuring truly universal protection against health risks.
And healthcare cost in the US would fall, as we got rid of the administrative waste
associated with our multi-payer health insurance system.
Sounds good! But it runs into 3 political hurdles.
First, while those who buy insurance would no longer have to pay for it,
the government would have to pay instead in the form of higher taxes.
This is a simple trade in theory,
but in practice, it feels like a politically traumatic tax increase.
Second, the 170 million Americans
who are by and large satisfied with their Employer Sponsored Insurance
would like to revolt against being fored into a single-government system.
And third, and perhaps the most important,
this would mean wiping out a nearly 1-trillion-dollor private health insurance industry.
This industry will not go quietly into the night.
As a result, single-payer is not a near-term political possibility.
So, where does this leave us?
I like the healthcare reform like bowling.
Our goal is to knock down all the pins
that block us from universal health insurance.
But we have to be careful not to throw the ball too far to either side,
in which case we could end up in the gutter,
of millions of newly uninsured facing discriminatory insurance coverage,
or the gutter of political impossibility leading to inaction.
Fortunately, there’s plenty of room down the lane,
for creative approaches like a public option
or expanded tax credits.
We just have to keep throwing the ball between the gutters
till we knock down all those pins.
I used to start all my healthcare speeches with a joke,
that’s well known among the health policy wonks.
The health economist dies and goes to heaven
and when she gets there, she’s told she can ask God one question.
So she asked, “Will we ever see universal health insurance coverage in America?”
To which God replies yes, “but not in my lifetime”.
I’m proud to say, I don’t use that joke in my speeches anymore,
because we have shown the willingness to take the difficult steps necessary
to fundamentally expand health insurance in America,
and Americans wanna move forward to build on the ACA,
not backwards to the bad old days of discriminatory insurance.
I don’t know how we’re gonna get to universal health insurance coverage in America,
but I know we will eventually,
because it makes economic sense,
it makes political sense and it’s the right thing to do.