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The American Journal of Managed Care February 2020
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Do Americans Have the Political Will to Tackle Healthcare Costs? A Q&A With Gail Wilensky, PhD
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Do Americans Have the Political Will to Tackle Healthcare Costs? A Q&A With Gail Wilensky, PhD

Interview by Allison Inserro
To mark the 25th anniversary of the journal, each issue in 2020 will include an interview with a healthcare thought leader. For the February issue, we turned to Gail Wilensky, PhD, an economist and senior fellow at Project HOPE.
Am J Manag Care. 2020;26(2):56-57.
AJMC®: When AJMC® launched in 1995, it was shortly after the Clinton healthcare plan had gone down in Congress and 15 years before the Affordable Care Act (ACA) was enacted. Now, more Americans have health insurance, but struggles with price, cost, and access remain. What will it take for the United States to bring down the cost of care and widen access?

Gail Wilensky: Doing something different from what we’re doing now: Either more aggressively trying to control costs directly, or putting in place a more competitive environment than we now have experienced. If we keep doing what we’ve been doing, which seems to be what most Americans are most comfortable with, we’re likely to have results very similar to what we’ve had.…Bringing down the cost of healthcare is extremely challenging; at least slowing the growth rate to the level of the economy, or less, should be possible, although that’s not so easy either. We have just learned from numbers being reported from CMS for the national health expenditures that in 2018, we actually did see healthcare spending relative to the economy drop slightly—still robust spending growth, but because we are in a strong economic period, a little less than the economic growth—and so the share of spending on healthcare dropped from 17.9% to 17.7%. That doesn’t necessarily mean it has been easier for people who have high deductibles to be able to access the insurance that they have.

AJMC®: Right, we saw one survey that said about 50% of people are skipping care or prescriptions because of the out-of-pocket costs.1

Wilensky: That’s a much higher number than I’ve seen, but it is definitely a problem for some people some of the time and the question of what can be done to help them is…not an easy question to answer. There are opportunities to set aside funds that can be used to cover some of the costs of high deductibles, the various types of tax-preferred accounts. But for people who are low-[income or] low- to middle-income, that may not be enough to attract them or to be able to be of use to them. I think the kinds of strategies that it would take to actually lower healthcare spending are likely to be politically very unpopular. It would have restrictions on access in terms of a very open-ended healthcare system, allowing most people to go where they want when they want as long as they have coverage. And it would take some amount of time for people in the United States to accept some constraints. Those of us who were around in the 1990 period remember how much pushback there was when managed care was first being introduced by employers as a strategy to slow spending, and people realized that they would either have to stay within network or, if they wanted to go outside of network, pay an increased coinsurance or co-payment, and they didn’t like that at all. That’s a relatively mild way to try to lower spending, but for Americans who are not used to that, not a very popular one.

AJMC®: That system is used in other countries, right?

Wilensky: Yes…there are all sorts of ways that we could try to either slow the growth rate or even lower the growth rate. But it would mean doing something different from what most Americans are accustomed to doing. And that’s really the challenge, getting people to agree that they’re comfortable with making some significant changes to how we access care.

AJMC®: Speaking of care, do you think value-based care has a future, or—without some other shift, like the one that you’re talking about—is emphasis on value just nibbling around the edges of this problem?

Wilensky: Well, the concern I have is [that] we frequently label value-based care [as] care where only a very small portion of the payment is actually related to value. So some of the [potential shift] might be related to value. If we were talking about a much more aggressive way to impact spending—in terms of either not funding or funding at a very differential level areas that were of questionable appropriateness, clinical appropriateness, or clinical value—I think we would have a chance to have a much bigger influence. Again, there better be a real heart-to-heart realistic talk with the American public to make sure they understand what they’re buying into if we were to move to that kind of system. In general, no politician has been willing to have those kinds of tough discussions with the American public. We’ve designed a very open, innovative healthcare system for those who are insured, which, thanks to the Affordable Care Act, is the vast majority of people in the country, a good 90%. Many of them are able to access care, especially if they stay within their networks, at reasonable costs. People who have either esoteric illnesses or who have high deductibles without having a way to cover them are in a different position and are not faring nearly so well.

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