Making Health Care More Available

The Problem

• Uniquely in the world, the American health care system is a mosaic of different funding sources, coverages, and structures. The most effective way to deliver better care and lower costs is to design reforms that recognize the reality of the system we have inherited, and improve it.
• Today the health care policy debate is too often an elite back and forth about the various ways to pay for insurance that can overlook the problems people face when they experience health care. Solutions must address the changes Americans consistently say they want: lower costs and higher quality. 
• The needs of patients and individual health professionals too often take a back seat to the profit drives of monopolies that increasingly control health care. Conglomerates merge insurance and care to maximize profits and devalue patient choice. Hospital corporations corner the market in communities across America, driving up prices.
  
• Americans who lack coverage can glimpse the advances of modern medicine only through a locked door. Without insurance coverage, they cannot access routine care, must delay needed medicines and treatments, and worry that any illness could cost them their savings, their job, or their home.
• Our health care system also fails those who have coverage. Millions of Americans who have coverage face barriers to medical care from spiraling costs, insurance rules designed to deny care rather than improve it, and long waiting times and high costs even for basic primary care.
• The Affordable Care Act was an important step toward addressing these deep-seated problems — but it was always intended to be a “starter home,” as President Obama rightly termed it. Now is the time to upgrade that starter home by making health care work better for all Americans.

The Terrain 

• Given the complexity of the American health care system, it is not surprising that people’s views on diagnosing the problems and finding solutions are complex, too. There is a “dislike the system but like my plan” dynamic at play: Although 76% of Americans are either very satisfied or somewhat satisfied with their own health coverage, 59% are either very or somewhat unsatisfied with the health care system as a whole.
  
• More Americans (34%) report trusting private insurance companies than the government (19%) to provide health care. 
• While a majority of respondents feel that the government has a responsibility to ensure everyone has health insurance coverage (57%) and receives basic health care services (60%), opinions are divided on how the government should meet this responsibility: 24% think that there should be a single national health plan, while 30% feel there should be a mix of public and private plans, and 26% feel the government should provide coverage to the poor and to seniors.
  
• These findings reinforce the idea that there is no single, unitary “American health care system” — nor do most Americans want to impose one. Instead, Americans experience health care through the lens of their own coverage and health care providers.
• Our solutions should reflect that diversity by giving Americans more and better options that make health care in all their systems more available, more affordable, and more responsive to the most important people in their health care system: patients and their families.

Having insurance coverage does not, by itself, solve the problems of American health care, but having coverage is the prerequisite for good care. Building on the inarguable success of the Affordable Care Act (ACA) to make health care coverage available for millions more Americans is a foundation for other needed reforms.

Recognizing that Americans get coverage from a variety of sources, these recommendations will make health care more available and involves significant changes to both public and private sources of coverage:

1. Making primary care free for all Americans, regardless of coverage source
2. Creating a nonprofit public option, the American Health Gateway, to be available to all Americans in need
3. Restoring extended ACA subsidies responsibly by concentrating on states that have done the right thing for their people by expanding Medicaid
4. Recognizing the richness and diversity of modern families by expanding access to private health insurance for extended families
5. Reforming Medicaid to remove needless barriers to enrollment and coverage
6. Expanding the health care workforce to serve all Americans

Free primary care

Sometimes the best ideas are the simplest: Primary care should be free to patients at the point of care. Around the world, patients can walk into a doctor’s office or urgent care center and receive the primary care they need without charge to them. Americans should have the same freedom. The ACA required insurance companies to cover some needed primary care, such as vaccines and recommended preventive services. It is now time to extend that policy by requiring coverage of all primary care.

The ACA also covered preventive services and an annual wellness visit for all Medicare beneficiaries. Millions of seniors have used this benefit to get screening and advice on keeping healthy and active. This successful model should be expanded to cover all primary care for people on Medicare or Medicaid.

Free primary care will work the same way that making preventive services free at the point of care works in the ACA. No cumbersome reimbursements, no forms to fill in or apps to download. Today, when you get a vaccine or other needed preventive service, you simply don’t pay out of pocket. This provision takes the next logical step from that important provision of the ACA by making basic primary care too. Critics said the sky would fall in when preventive services were made free as part of the ACA and they’ll say the same thing again now. They’ll be wrong both times.

The American Health Gateway

Too often in America’s health care system, the drive for profit trumps the needs of patients. To counteract this balance, we will create the American Health Gateway, a nonprofit coverage option offered in every state. The Affordable Care Act envisioned a nationwide expansion of Medicaid to provide a floor of coverage for all low-income Americans, with the ACA marketplaces intended to rest on top of this foundation. Forty-one states have done the right thing by expanding Medicaid to give millions of lower-income Americans better options for health care. 

These states will have the choice of including the Gateway within the framework of their ACA marketplaces as an additional nonprofit option for coverage. Just as a state can choose either to operate its own ACA marketplace or default to the federal platform, states may choose whether to include Gateway plans in their state exchanges — meaning that residents of states who don’t elect to include the Gateway plans in their own exchanges could still access those plans through a federal entry point.

 Over time, the American Health Gateway will offer Medicare Advantage plans as a nonprofit competitor to the for-profit plans that now receive billions of dollars in overpayments from American taxpayers every year. This competition will be one aspect of reducing these overpayments, thus helping Medicare save money and extending the solvency of the program. Congress should enact the recommendations of the expert Medicare Payment Advisory Commission on technical improvements to the data used to calculate payments, so that payments to plans are more accurate.

In states that have shirked their responsibility to expand Medicaid, the Gateway will also provide (with no state option to decline) a statewide fallback plan separate from the marketplaces to provide Medicaid coverage for low-income adults that the state has failed to provide. States that have not done the right thing for their low-income patients would have no say in the design of the Gateway plan.

Responsibly restoring ACA extended subsidies

The promise of the ACA to expand coverage options was only partially fulfilled in the law’s original form. Subsequent improvements have helped the ACA cover more Americans. Chief among these were the extended advance premium tax credits later provided under the ACA. These credits helped millions of Americans afford coverage, but they were allowed to lapse at the end of 2025. We should fully restore these expanded subsidies for those states that have done the right thing for their people by expanding Medicaid.

States such as Florida and Texas have shirked their responsibility to expand Medicaid and have instead relied on the rest of America to provide national subsidies to pay for their irresponsibility. America should not continue to subsidize states that fail to take responsibility for the health care needs of their people by providing new ACA extended premium tax credits in those states. 

Recognizing the richness and diversity of families

The ACA recognized the reality of families today, which is that kids often need to be on a parent’s coverage into young adulthood. That’s why the ACA required insurers to cover young adults up to the age of 26 on a parent’s plan. But family isn’t just parents and children. Millions of Americans are responsible for the care of a parent-in-law or grandchild — or a loved one who is not related but is still family in their hearts. Health care should recognize the richness and diversity of family relationships by building on the model of the ACA to allow people who have private health insurance to designate any loved one as a family member and include them in their coverage. People who are covered under an employer plan would have the option to add as many additional loved ones as are covered under the existing employer plan. Thus, a person covered under an individual-only plan could add one additional loved one. Someone covered under an individual + spouse plan could cover two, and so on. The plan would be allowed to charge an additional premium up to the cost of an additional adult or child.

Removing the barriers to care for Medicaid

Medicaid is a lifeline for millions of working families, but that lifeline is often placed out of reach by arcane rules and mountains of red tape that serve no purpose but to deny care. We should ensure that everyone who is entitled to Medicaid receives it by simplifying administrative processes for enrollment that are often dizzyingly complex and eliminating needless bureaucratic barriers to participation. These policies will help millions of Americans whose income fluctuates over the year — such as gig workers, construction workers, or single parents — retain coverage and have a continuous source of care. 

Increased enforcement against fraud and abuse

Reforms to make Medicaid more accessible should be paired with rigorous enforcement to guard against fraud and abuse. Investment in program integrity for Medicare and Medicaid returns millions more dollars to the public than it costs, through recoveries from fraud and abuse. We should fully fund integrity and enforcement for these public programs and for plans offered through ACA marketplaces.

Who benefits from these reforms?

Administrative simplification can sound very dry and disengaged from people’s lives — but it is just the opposite. These reforms can mean the difference between staying healthy and being unable to work or care for children for millions of Americans. Consider a construction worker who has little work in winter, so his income is at 120% of the Federal Poverty Level (FPL). He would be eligible for Medicaid at that time, but gets work in the warmer months, bringing his income to 150% of FPL. Without continuous eligibility, he would lose access to health care and perhaps needed medicines during the months when his income rises.

Simplifying the administrative processes of enrolling in Medicaid — which can be bafflingly complex — helps those who have low literacy, speak English as a second language, or have minimal access to the internet. Consider a restaurant worker who can find only part-time shifts. As a result, she moves from one apartment to another, or stays temporarily with friends to make ends meet. She may not receive mailed notices from the state Medicaid agency or may be unable to complete required forms — but she should not lose health care as a result. 

Expanding the health care workforce to serve all Americans

Making quality affordable health care a reality for millions more Americans will of course require that the health care workforce expands and that health care itself becomes more efficient through responsible use of technology such as telehealth and AI.

We should also invest in health care professionals, particularly those who practice in underserved areas. Measures to do so include expanding the number of physician training slots, potentially reducing the time spent in medical school by improving the use of technology, strengthening loans for service programs, bringing in talented health care professionals from other countries, and encouraging non-physician professionals to utilize their skills to the fullest.