To Know Where Health Care is Going, You Have to Know Where It Has Been

November brings the opening of enrollment for 2017 health insurance coverage under the Affordable Care Act (ACA), as well as new questions about the sustainability of the health insurance marketplace created by ACA. The market in many areas of the country is experiencing double-digit increases in premiums coupled with major insurance carriers withdrawing coverage. Will the ACA reforms work? Have they worked? These are questions that have been asked and will continue to be asked on a regular basis due to the continuing complexity and uncertainty of the U.S. health care system.

To understand where we are going, it is essential also to understand where we have been and how we got here. The newest edition of Introduction to U.S. Health Policy addresses the questions surrounding ACA in the context of the history of health policy in our country. Was President Obama accurate when, upon signing ACA in 2010, he indicated that the U.S. had, “enshrined the core principle that everybody should have some basic security when it comes to their health care”? Do we as Americans have a right to health care? We have been debating this issue for nearly a century, and still aren’t quite sure.

There is even more debate over what role government should play in financing and regulating health care. The schism that followed the 2012 Supreme Court ruling confirming the constitutionality of ACA while removing the requirement that each state expand its Medicaid program has left millions of poor people without health insurance in states electing not to succumb to federal expansion efforts. Do those people have any “basic security when it comes to their health care”? These are some of the same questions we dealt with in the 1960s when Medicaid was first established. We debated them then, and we are debating them again now.

Perhaps even more perplexing is the issue of how doctors, hospitals, and health insurance providers will relate to each other in the rapidly changing world of private health care delivery. HMOs have been replaced by ACOs (Accountable Care Organizations) as the model of care delivery seen as having the potential to constrain the rising cost of care while maintaining quality. Many HMOs crashed and burned in the 1990s following the “managed care revolution.” Will ACOs survive? Can doctors, hospitals, and nursing homes learn to work together under a single “bundled payment” for providing care? Will “fee-for-service” survive as the principal method of paying physicians for the care they provide?

Shortly after ACA enrollment opens, we will also elect a new President and a new Congress. The outcome of these elections will doubtless lead to increased intensity in the debates surrounding the future direction of U.S. health policy. We could be facing déjà vu all over again. For those who either will be following these issues or who hope to be involved in their resolution, I encourage you to become familiar with U.S. Health Policy in the context of our national history, culture, and economic system.

Donald A. Barr, MD, PhD, is a professor at Stanford University in the Department of Pediatrics. He is the author of Health Disparities in the United States: Social Class, Race, Ethnicity, and Health and Introduction to Biosocial Medicine: The Social, Psychological, and Biological Determinants of Human Behavior and Well-Being. His latest book, Introduction to U.S. Health Policy: The Organization, Financing, and Delivery of Health Care in America, is available now.