In the shadow of a global pandemic, national unemployment crisis, and ongoing presidential impeachment hearings, the debates surrounding Medicare for All that dominated news cycles through the summer and fall of 2019 may seem like a quaint and distant memory. However, as a newly minted Democratic-controlled legislative and executive branch elected on the promise of Medicare for All look to define policy priorities for the next four years, we in healthcare would be well served to consider how we might shape discussions of healthcare reform in the years to come, particularly given the unique spotlight the pandemic and race-related protests have placed on health disparities. There is no denying that public attitudes about healthcare reform have shifted dramatically over the past quarter-century, with 2017 marking the first year a majority of Americans supported government-instituted national health insurance coverage and 74% of Americans now reporting that they would like to see the government do more to provide care for all citizens.1 Yet, for all the political success of the Medicare for All campaign, universal healthcare coverage—even if achieved—in reality, represents not a panacea but one piece of the comprehensive healthcare reform needed to achieve improved health for all in the United States.
Identifying the other components and priorities of meaningful healthcare reform is no easy feat, but it is a necessary one. Doing so ultimately requires that we, as a society, achieve consensus on our healthcare values and begin to engage in discussions of costs and tradeoffs involved in the daily application of health policy. If achieving health equity ranks among these priorities as so many recent editorials and calls to action in the cardiovascular community demand, a reimagining of how we define healthcare quality is required. The American healthcare system has become notorious for its nearly singular focus on individual-level outcomes in measuring healthcare quality, but in doing so population-level performance, and in turn disparities in care, have been largely ignored at the system level. This is to the detriment of minority and underserved communities who experience ill-health in greater numbers, as well as the larger population, all of whom share in the downstream effects of rising healthcare costs driven by acute and tertiary care services. While providing universal coverage may lower or eliminate one barrier to care for underserved groups, unless paired with interventions to reach underserved populations, expand primary and preventive care resources, lower drug costs and expand access to preventive therapies, gains in health equity are unlikely to be achieved.
There are few better examples of this than in the case of cardiovascular disease, which affects more than 80 million people in the United States and is one of the largest single drivers of health expenditures, costing about $444 billion in direct healthcare costs and accounting for $1 of every $6 in health spending.2 Healthcare costs in cardiovascular care have continued to rise and are estimated to reach $818 billion in direct costs and $275 billion in lost productivity by 2030.3 This is, of course, largely preventable. Reductions in the prevalence of smoking and hyperlipidemia, improved recognition and control of high blood pressure, and expanded access to aspirin and statin therapy over the past four decades have driven substantial and consistent declines in cardiovascular mortality. However, disparities by gender, race, and geography remain unchanged in the same time period, demonstrating that while prevention is key in reducing the burden of cardiovascular diseases, unequal access to services and interventions and failure to engage systems of discrimination and racism will continue to hinder our progress toward improved cardiovascular health for all.
So how can we, as cardiologists, begin to reimagine an approach to prevention that meets the magnitude of the current demands for a better and more equitable healthcare system, while also not further ballooning spending? Doing so will require innovative thinking about how to deliver high-value care, a lesson we may well gain from studying the examples of resource-limited settings. Too often, we have seen the American healthcare system as incompatible with models of healthcare from low- and middle-income countries, but these countries and systems offer valuable lessons in how to reach vulnerable populations and provide high-quality care at low cost. This is not to say that any one country has fully achieved the vision of healthcare to which we strive, but rather to suggest that we may improve our own performance by broadening our approach to resource-limited care and embracing ideas with demonstrated efficacy. Over the course of this series which will roll out over the next 3 months, I’d like to explore some of these approaches and their respective strengths and weaknesses, starting with models of task-shifting, use of mobile health technologies, and polypills among others, specifically imagining how such interventions may apply to cardiovascular health in the U.S. and may act to reduce disparity and improve cardiovascular outcomes. These interventions are by no means comprehensive nor capture all of the intricacies of healthcare reform policy but may help us to identify tools at our disposal as we consider how healthcare may function to promote equity while improving health outcomes. By doing so, I hope we can begin to see how a vision for “Medicare for All” might eventually evolve to a vision for “Health for All”.
- KFF. Public Opinion on Single-Payer, National Health Plans, and Expanding Access to Medicare Coverage. 2020; https://www.kff.org/slideshow/public-opinion-on-single-payer-national-health-plans-and-expanding-access-to-medicare-coverage/. Accessed February 11, 2021.
- Shaw LJ, Goyal A, Mehta C, et al. 10-Year Resource Utilization and Costs for Cardiovascular Care. J Am Coll Cardiol. 2018;71(10):1078-1089.
- Heart Disease and Stroke Cost America Nearly $1 Billion a Day in Medical Costs, Lost Productivity. 2015; https://www.cdcfoundation.org/pr/2015/heart-disease-and-stroke-cost-america-nearly-1-billion-day-medical-costs-lost-productivity#:~:text=Annually%2C%20about%20one%20in%20every,costs%20could%20exceed%20%24275%20billion. Accessed February, 2021.
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