I recently submitted a Statement for the Record to the U.S. Senate Committee on Finance for their November 19th hearing, “The Rising Cost of Health Care: Considering Meaningful Solutions for All Americans “ to provide support to the committee in considering both short-term and long-term insights that may inform the committee’s drafting of bipartisan solutions for American healthcare. An excerpt from my statement is shared below: 

Why the Status Quo is Unacceptable

I am deeply interested and invested in supporting this committee’s critical work in advancing a health policy solution for America.  Our lives and future as a country, literally depend on it: our ability to have a healthy workforce and tax base, address declining life-expectancy (we are ranked 48th in the world) and even national security (we must have healthy young men and women who are military-ready, and our teens/young adults are floundering triggered by anxiety and mental health woes).  

To that end, I believe it’s critical to change the way we think about healthcare in America; we must shift from a conversation about coverage to a conversation about infrastructure. 

Before I provide details about infrastructure and other topics, I want to acknowledge that these solutions will require time to develop and implement effectively. Though the tax credits are certainly not without problems (in incentivizing the wrong actions by insurers), in the short-term, there is no other solution to extending the enhanced premium tax credits for at least one year, to prevent the high premium increases, and loss in coverage, a cliff that Republican constituents will be most impacted by. We must then turn our attention to both interim and longer-term healthcare infrastructure solutions. 

Short-Term Stopgaps: Stopping the Bleeding

  1. Having the Centers for Medicare and Medicaid Services (CMS) facilitate the development of all-payer national clinical coverage guidelines, aligned quality improvement measures, and provider pay-for-performance incentives for delivering care according to guidelines. Having national guidelines of healthcare will prevent healthcare providers from having to guess what is covered and not by one insurer vs. another.  National guidelines will also ensure consistency. Why should one insurer declare a service medically necessary and another say it’s not? 
  2. Limit & streamline prior authorization by having providers submit requests for care that fall outside of the above-mentioned guidelines, through a singular prior authorization clearinghouse/gateway (limiting the administrative time for providers to request such exceptions). The gateway can incorporate responsible artificial intelligence (AI) to determine if an exception/prior authorization is warranted. 
  3. Address MLR gaps by requiring for-profit commercial Insurers to contribute 10-20% of revenue into a Federal Health Innovation Fund. The ACA created guardrails referred to as medical loss ratio (MLR), intended to require insurers to spend 15-20% of revenue on patient care, and reimburse patients for excess profits. While MLR was designed to cap insurer profits, Insurers have used revenue to acquire provider and hospital systems, as well as pharmacies, including pharmacy benefit managers, rather than reimbursing patients. One way to address this is to require for-profit commercial insurers to pay 10-20% of all revenue into a Federal Innovation and Infrastructure Fund (FIIF). Funds could be used to pilot solutions like a Federal mental health consultation program for all primary care providers to support the diagnosis and management of depression and anxiety disorders, so that psychiatrists are reserved for more complex and severe mental health disorders. Innovation funds could be used for other solutions, such as piloting regional maternity care centers in maternity care deserts, where no labor and delivery units and/or obstetric and gynecological (Ob/Gyn) services exist. Commercial insurers recognize these gaps in care and are willing, and perhaps eager, to solve these gaps through a tax/FIIF structure.
  4. Agents and Brokers, not insurers, are enrolling people without their knowing in the ACA exchange; that’s fraud. The Federal government should crack down on this type of fraud by introducing legislation that would charge agents/brokers who commit fraud with a federal crime. This legislation could also require commercial insurers to report any enrollees with no healthcare utilization in the prior year to a Federal body for investigation.
  5. Congress should pass a law to put in place short-term guardrails on what is permissible. This should include preventing the sale of high-deductible health plans. HDHPs are forcing patients to forgo routine preventive care, and are forcing Americans who have an unplanned need for care into outrageous medical debt and bankruptcy. Even insurers are getting in front of the consumer hardship and are now marketing a simple HMO (with a side of AI) as a “new” type of plan with no deductibles or coinsurance.

The Long-Term Solution: Healthcare as Infrastructure

However, healthcare is not like manufacturing, where a widget can be purchased online at any time when needed. Instead, there are several factors (not just insurance) that are necessary: 

  1. The availability of providers/services/solutions in every community (think about the universal availability of post offices and libraries for comparison) 
  2. Universal guidelines for covered care 
  3. Fair payment for that care 
  4. Insurance for catastrophic needs, like car accidents, and unexpected specialty care

A completely private market cannot control for these needs. Instead, there are perverse incentives. If private insurers and Medicaid/Medicare don’t pay what a hospital or primary care provider feels is necessary to operate in a particular community, that provider/facility will simply close. Likewise, insurers can also decide to leave geographic markets or product lines (like Medicare Advantage, Medicaid, or Small group for example). 

As mentioned above, to truly improve the health of Americans and have a ready workforce, it’s time for America to change our paradigm and view healthcare as infrastructure, similar to roads, schools, police, libraries, the Department of Motor Vehicles, and more. All Americans have access to this infrastructure, and all should have access to healthcare infrastructure.

Let’s implement short-term stop-gaps in 2026 and develop a plan for permanent healthcare infrastructure, examining the best healthcare systems in the world.