Part 1: Thoughts on Universal Coverage, Health, Equity and Value

Hon. John Kitzhaber is the former governor of Oregon and continues to be one of the most important thinkers on state health reform in the country. Since leaving public service, he has traveled across the country, working with organizations, leaders, and reformers in health care. 

This commentary is the first in a three-part series offering Kitzhaber’s thoughts on universal coverage, equity, and value. In this part, he reflects on the recently passed $1.9 trillion American Rescue Plan. The next parts of the series, which will be released in the coming days, dive into the details of his ideas to move the national health policy agenda forward.  


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Wednesday, the House ratified the American Rescue Plan, sending the $1.9 trillion COVID and economic relief package to President Biden for his signature. While many components of this legislation are absolutely necessary, it is discouraging to watch this dramatic increase in public subsidies for the U.S, health care system with no provisions to address the structural flaws in the underlying system. With the exception of a public option, the American Rescue Plan incorporates many elements of the health policy agenda the president laid out in his campaign—particularly increasing the size and the scope of the public subsidies in the ACA market.

The debate continues to be focused almost exclusively on making health care more affordable to individuals by increasing public subsidies, which is not the same as reducing the cost of health care itself. Increasing public subsidies has been the central strategy to expand access in the U.S health care system since the enactment of Medicare and Medicaid in 1965, it was the same strategy used in CHIP and the ACA— and this strategy has benefited millions of Americans. At the same time, the cost of the U.S. health care system—driven by inefficiently, greed, and the lack of accountability — is approaching $4 trillion a year, undermining our ability to make the social investments necessary to improve the health of the population and address long-standing racial and ethnic disparities. We are missing the forest for the trees.

There is nothing, nothing to suggest that unrestrained market forces will solve this problem—on the contrary they are fueling it. This past year alone—in the midst of the pandemic and a terrible economic downturn, when millions of Americans were losing their health insurance, when one in six people were going to bed hungry and millions faced unstable housing—health care IPOs raised more money during must the first three quarters, than during each year from 2015-2019—almost $30 billion. That’s not market competition—it’s an extractive industry looting the public treasury.

Congress can run only two reconciliation bills per session and the current American Rescue Plan is the first one. Any major non-COVID health policy will have to go into the second reconciliation package this summer or fall because with the 50-50 tie the Senate there’s no other way to overcome a Republican filibuster. Furthermore, whether congressional Democrats have the will to weigh down the second reconciliation package with major health policy initiatives like a public option (going into an election year) is problematic for a number of reasons: (1) “health care fatigue” through the pandemic, (2) feeling that health care did not “deliver” politically in the 2020 election, the way it did in 2018, (3) fear of industry backlash over “value” reforms, and (4) fear of opposition messaging in 2022 (socialism, anti-immigration, etc.).

At the same time, we cannot simply wait another two years, hoping that the 2022 midterms will significantly change the political dynamics inside the Beltway. So, here are a few thoughts on how to move the national health policy agenda forward administratively through 1115 and 1332 waivers.

Part 2 of this commentary is available here and Part 3 is here