How Can the U.S. Achieve Universal Coverage? With a Two-Part Plan, Expert Says

What’s the best way to ensure that everyone in the U.S. has health insurance and access to care? Amy Finkelstein, PhD, who has studied health economics for 20 years, is pretty sure she finally knows the answer.

After her father-in-law challenged her to tell him what was needed to fix the healthcare system, Finkelstein, at the Massachusetts Institute of Technology in Boston, and Liran Einav, PhD, an economics professor at Stanford University, California, wrote the book “We’ve Got You Covered,” to attempt to answer that question.

As for achieving universal coverage and access, “it’s two parts,” Finkelstein explained Thursday at an event in Washington, D.C., sponsored by the Brookings Institution and The Hamilton Project.

The first part is “universal, automatic, basic coverage that’s free for all patients” and funded by the federal government. “And then there’s the option — for those who want and can afford it — to be able to supplement that with their own money in a well-designed and well-functioning supplemental benefits program.”

What would be included in the basic plan? For starters, “primary care, preventive care, prescription drugs, emergency care, and hospital care — everything essential would be covered,” she said. After that, “there’s a big gray area — and other countries have gone through this — ‘Do we cover infertility treatments? Do we cover physiotherapy? Do we cover Viagra? Do we cover dental?’ The answer is, it depends in part on what we decide the budget is, and how decisions are made.”

The basic coverage program would be a lot like Medicaid, but with one important difference, she said: no one can lose eligibility or get kicked out of the program.

“One in four Americans under 65 will spend some period of time without health insurance over a 2-year period, and when they do, they’re often uninsured for a long time,” said Finkelstein. “That’s both people with employer-provided health insurance and people with Medicaid, who risk losing that coverage if their eligibility changes or if they just fail to file the paperwork to prove that they remain eligible.”

Finkelstein said one area that wouldn’t be covered is “non-essentials.”

This would be similar to what happens in Singapore, where hospital patients without supplemental insurance “recover in a hospital room with 10 beds, and in a notoriously hot and humid climate, the brochures refer to the basic plan as providing ‘natural ventilation’ in the rooms,” said Finkelstein. “But if you supplement, as many people do, at the highest end you can get a private, air-conditioned room with a private bath, high-speed internet, and very good food … So non-medical amenities would be less good than probably what most private plans or Medicare will get you.”

Another area in which the basic plan would differ from a supplemental plan would be wait times, she said. “Wait times for non-urgent care in Medicaid are longer than they are if you have private insurance or Medicare,” although they’re about the same length as in the Veterans Affairs system.

Finally, the basic system would include more “coordination of care” — things like prior authorization. “Traditional Medicare famously doesn’t have that,” Finkelstein said. “Medicare administrative costs are extremely low because it doesn’t ‘administer’ anything — it just pays the bills” for whatever service the doctor performs or orders.

As a result of these differences, “we suspect that people who currently have Medicaid would actually be better off because they wouldn’t risk losing the coverage,” she added. “The uninsured would also be better off, but the half of the population that has private health insurance primarily through an employer, and the fifth of the population that currently has Medicare, would probably all supplement” to get better benefits.

Asked about whether a basic plan would cost the government more than it’s currently spending on healthcare, Finkelstein said she didn’t think so.

“Our tax dollars are already spent contributing 9% of GDP [gross domestic product] to healthcare spending,” she added. “That’s about how much on average the [developed] countries pay for their universal basic coverage. We’ve just chosen to spend it differently.”

“The U.S. already spends twice as much as any other high-income country — as a share of the economy — on healthcare, but in most other high-income countries, that’s essentially all publicly financed, whereas in the United States, only half of it is publicly financed,” with the rest paid by employers and patients. “And you know, half of twice as much is the same amount,” she said.

Not unsurprisingly, some people disagree with the authors’ ideas for getting to universal coverage.

One of them is former Rep. Henry Waxman (D-Calif.) who now runs his own consulting firm. “The best we can do is incremental changes, if that,” he said during a separate panel at the event. “Incremental changes become very important to the people who are affected. We started off with 50% uninsured; we’re now down to 7% uninsured. That’s a great accomplishment.”

“We have to remember that we had to fight back the attempts to weaken what we already had,” Waxman continued. “We were able to keep the Affordable Care Act by one vote in the Senate … But we still have it and people would be outraged if we repealed the Affordable Care Act now, just as they would be outraged if we repealed Medicare or veterans’ healthcare or anything that is now part of the system that we have, even as incomplete as it may be. So I don’t want us to lose hope.”

Now that the book is finished, Finkelstein said, “I don’t plan to do more research on health insurance because I feel I’ve solved the intellectual problem, and I want to work on healthcare delivery … where I feel like there’s still a lot of unanswered questions.”

“I work on things that I don’t know the answer to; if I knew the answer, then I would work on something else,” she said.

Joyce Frieden oversees MedPage Today’s Washington coverage, including stories about Congress, the White House, the Supreme Court, healthcare trade associations, and federal agencies. She has 35 years of experience covering health policy. Follow

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