The Golden Age of Medicine Needs a Golden Age of Coverage

It will be difficult for the patchwork that is U.S. healthcare policy to bridge the gap.

"We may be on the cusp of an era of astonishing innovation," notes a June feature from New York Times Magazine. "[T]he limits of which aren't even clear yet."

One limit is clear: insurance can't keep up with these innovations.

The ACA has provided new coverage options for a now record-breaking 16.3 million Americans. This includes people who are without an employer-sponsored plan, gig workers and the self-employed, and those who are between coverage. That is a near-miraculous innovation in itself, given today's political climate.

However, 8 to 24 million Medicaid members may lose their coverage after post-COVID eligibility redeterminations. And while the uninsured rate dropped 18% during the pandemic, 27.6 million Americans still lacked coverage in 2022.

But back to those Golden Age treatments.

Vaccines, gene therapies, and prescription drugs

Times author David Wallace-Wells cites multiple examples, leading with coronavirus vaccines and:

• Gene and immunotherapies, including for cancer;
   
• New drug-development pathways driven by machine learning; and
   
• Off-label uses of the diabetes drug Ozempic, whose potential has expanded beyond weight loss to Alzheimer's, Parkinson's, polycystic ovary syndrome, addiction and alcohol use disorder, even cancer.

But how many innovations will be affordable, even for the insured? Wells reports that drug development costs "have doubled every decade since the 1970s." As for gene-based therapies, he adds that 400 million people worldwide have single-gene mutation diseases that Crispr gene-editing could fix. The two newest (sickle-cell anemia) would cost an estimated $2 million per patient.

"The deep-seated rot in US health insurance coverage"

Two days after Wells' article appeared came We've Got You Covered: Rebooting American Health Care. Authors Liran Einav and Amy Finkelstein start their book with a bang, citing the "deep-seated rot in US health insurance coverage." The source of the rot? The patchwork that is U.S. healthcare policy, forged from crisis response and plugged coverage gaps versus a unified approach. Other rots they cite include exorbitant consumer cost-sharing that deters treatment and can bankrupt even the insured users of care.

"When patients have to pay more for medical care, they use less of it . . . If cost sharing is large enough to have a meaningful impact on medical spending, it interferes with the primary function of health insurance, which is to protect people against the risk of having to pay large medical expenses."

The Covered authors note that collection agencies hold $140 million in unpaid U.S. medical debt—60% from people who have insurance. But the cost burden starts long before that. Half of U.S. adults can't cover a $500 surprise medical bill.

What would their Golden Age of Coverage look like?

The We've Got You Covered blueprint

Covered's authors, Einav and Finkelstein, propose that people should be auto-enrolled in free, basic coverage: all essential care for critically ill patients but only primary and preventive care for those who are healthy. "The rest is gravy"—separate, optional insurance that sits "on top of existing basic coverage" and allows consumers to pay the difference and only for the extra supplemental benefits they want.

Insurance innovation won't be cheap either. The authors call for a "binding budget for basic coverage, just like all other high-income countries have." They add that the budget "would come out of taxpayers' pockets [which could] plausibly be financed out of existing tax revenue."

What about cutting costs? Einav and Finkelstein are clear it is needed but acknowledge the consequences and the "large body of evidence that when physicians are paid less, patients get less care. And when drug prices are lower, fewer new drugs are developed."

The authors' final proposal is to eliminate unnecessary care. Again, they cite the evidence, that "the tools we currently have at our disposal tend to throw the baby out with the bathwater — cutting high-value and low-value care alike."

Healthcare value originates from many places

Returning to COVID vaccine development in his Times article, Wells notes: "It is sometimes hard to see the silver lining for the cloud, particularly when it's as dark as the last three years have been."

"But the mRNA sequence of the first shot was designed in a weekend, and the finished vaccines arrived within months, an accelerated timeline that saved perhaps several million American lives and tens of millions worldwide."

Wells adds: "The miracle of the vaccines wasn't just about lives saved from Covid. As the first of their kind to be approved by the Food and Drug Administration, they brought with them a very long list of potential future mRNA applications."

This highlights that the Golden Age of Medicine and the Golden Age of Coverage must share: speed, innovation, collaboration, and new regulatory pathways. In addition to being a patchwork, U.S. healthcare policy also can't keep pace with innovation. Because policy can't keep up, coverage can't either.

Hype and hope, boom and bust

Wells writes that hype springs eternal in medicine, right beside the hope. It's important to acknowledge both. He also details that decoding the human genome "unleashed a venture-capital-like boom-and-bust biotech hype cycle that sputtered out before most Americans had seen any real gains from it." There is only one U.S. Crispr gene therapy, the others focus on testing and only two companies have submitted FDA applications for associated treatments.

The Affordable Care Act has generated a similar cycle. In 2016, Inc. Magazine declared the ACA a "gazillion-dollar startup machine." It was and is, with its own booms and busts. Perhaps the greatest venture would be to achieve the coverage Einav and Finkelstein describe.

"[O]ur reading of the historical record — both at home and abroad — leaves us sanguine about the possibilities for universal health care in the US . . . but we're confident it's not impossible either."

As Wells concludes: "Sometimes these things just take a little time."