The year 2020 marks the 10th anniversary of the Affordable Care Act. Recognized as the biggest change to our health care system since the creation of Medicare and Medicaid in 1965, many thought the Affordable Care Act (ACA) would make all of our health care problems disappear. On the contrary, it has proven to be a mile marker on a long road towards the finish line. While the ACA has had its share of successes, it also left many health care issues untouched. However one thing is for certain: we can expect a health care shift will take place based on the outcome of the 2020 presidential election.
Already dominating the Democratic debates, here are the hottest health care issues in 2020 that we will be hearing everyone talking about this year:
The Affordable Care Act—What’s Next?
The big question that needs to be decided in 2020 is what to do with the Affordable Care Act. This law was enacted to provide health coverage to many uninsured Americans including those with pre-existing conditions; it also mandated that insurance include coverage for 10 essential services (Preventive care, Maternity care, and behavioral health, to name a few). Today 9 out of 10 of Americans have health insurance. Half of Americans get their coverage through employers, 35% get coverage through Medicare and/or Medicaid, 7% buy direct from insurance companies, and roughly 9% remain uninsured.
The answer to how to move forward with the ACA is largely divided along party lines. While Republicans are looking to reduce federal regulation and funding, Democrats are focusing on expanding coverage. For Republicans, reducing regulation and spending means repealing the ACA, getting rid of Medicaid expansion and eliminating subsidies, and allowing states to respond with their own budgets rather than using federal funds for this purpose. For Democrats, expanding coverage can range from moderate solutions to cover holes left by the ACA such as a public option, to the more extreme solution of Medicare for All. However all of these options come at a cost.
Health Care Affordability
Right now health care in the United States is hitting people where they feel it most—in their wallets. Health spending currently stands at over 17% of the US GDP. Total health spending was estimated to exceed $3.8 trillion in 2019, and it’s projected to increase on average by 5.6% annually to reach almost $6 trillion by the year 2027.
A top concern for individuals are deductibles, or the amount that patients have to pay before their insurance kicks in. In the early 2000s, several economists suggested that if people had more “skin in the game,” they would become better shoppers for their health care. Fast-forward to today, and there is not clear evidence to show that deductibles are making people more responsible for their health. Now that deductibles are climbing to higher amounts in the several thousands of dollars (the average individual deductible is currently $1655), we have a problem. 4 in 10 people don’t have more than $400 set aside for emergencies, according to the Federal Reserve. So the hard truth for Americans is that many are just one illness away from serious financial hardship. One of the problems that the ACA failed to address is the issue of rising deductibles. Insurers knew they had to cover many more benefits under the ACA so many employers increased deductibles to be able to give mandated coverage while limiting the impact to their bottom line.
Surprise Medical Bills
Also in the theme of health care affordability is the issue of “Surprise Billing.” These are bills that patients get from providers outside of their network when there is no way they could have avoided the bill. While the patient may have deliberately chosen an in-network provider for their service, they could receive a surprise bill from a lab, radiologist, an anesthesiologist or assistant surgeon who was involved in their care. This is one issue where there seems to be bi-partisan agreement that a remedy is needed. 19% of Emergency Room admissions and over half of ambulance rides are out of network. This leads to higher premiums for everyone else, and is generally considered a market failure that needs to be fixed. But as with many issues within health care, it’s complicated. Patients are affected by the problem, yet providers are hurt by the reforms.
The complex concern of skyrocketing drug prices in the US to was supposed to be tackled in 2019, but industry lobbying and partisan divides prevented movement on this topic last year. The United States is unique because it does not regulate or negotiate the prices of new drugs that come on the market. Elsewhere in the world, countries task a government body to negotiate these prices. Because of our lack of cost-control measures, 23.3% of each health care dollar goes to cover the cost of prescription drugs, while some individual drugs have a price tag in the millions. The cost of free market innovation in this country has led to wildly fluctuating prices, where in some cases the same drugs can be purchased at a fraction of the cost abroad. House speaker Nancy Pelosi is calling to having this issue attached to a package of other expiring health care programs that need to be renewed this year. However it is uncertain whether this issue will be resolved before the looming election.
Each of the these hot topics in 2020 ultimately fit into two categories—issues around cost and issues around coverage. Health care topics continue to come back to the fundamental need to 1) control health care costs in the United States, and 2) control the what, who and how of health coverage. So much of the discussions at this early part of the year focus on which health care delivery model can fix the problems left unsolved by the ACA of affordability, while addressing the outstanding issues of wasteful spending. Adjacent issues that will receive attention are mental health, addiction and reproductive rights—all concerns still at the top of mind for Americans. The other looming issue that will gain more attention over the next 5 years as the American population ages is the unavailability and lack of affordability of long term care. Amidst this broad range of health care hot topics, here’s to hoping that 2020 will bring about meaningful solutions.
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