Economist offers 'startlingly simple' fix for U.S. health care system

June 2024

Amy Finkelstein says: Make essential care free for all, charge for upgrades

SAN DIEGO – Economist Amy Finkelstein says a way to meet what has historically been the nation's overriding imperative when it comes to health care – to provide access to essential medical care, regardless of resources – is "startlingly simple."

"I'll give it away now, so you're not on the edge of your seats for most of my talk," Finkelstein said at the start of her keynote address at the 2024 Catholic Health Assembly. "It's automatic, universal, basic health care that's free for everyone, with the option for those who want and can afford to, to supplement beyond the essential."

She added that the nation's social contract or moral obligation to see that everyone has basic care could be accomplished without raising taxes.

Amy Finkelstein opens the 2024 Catholic Health Assembly in San Diego with a keynote address on potential ways the U.S. could provide basic, universal care for all without necessitating a tax increase. Finkelstein is an economics professor at Massachusetts Institute of Technology.

Finkelstein is a professor of economics at the Massachusetts Institute of Technology, specializing in public finance and health economics. She has received numerous honors for her research, including a MacArthur Fellowship in 2018.

She used her address at the assembly to cover the key points made in her new book, We've Got You Covered: Rebooting American Health Care, which is based on research by her and her co-author, economist Liran Einav of Stanford University.

Unmet promise
Finkelstein said despite the Affordable Care Act's promise of universal coverage, many Americans are still left out. For example, she said, one in 10 of those under 65 are without insurance at any given time and one in four of that same group will have a lapse in coverage over a two-year period.

While the law reduced the share of Americans who are uninsured, Finkelstein said, it did little to cut the share of people at risk of losing coverage. That's because it further expanded what was already a patchwork of programs to provide health insurance, she said.

"Unfortunately, what happens is, if you have multiple different pathways to eligibility, some people don't find their path or don't have a path," Finkelstein said.

She said one of the most startling statistics cited in her book is that six of 10 of those who are uninsured are eligible for free or heavily discounted insurance. They aren't covered for various reasons, she said, including not knowing what programs are available, whether they qualify for any of them or how to continue to prove that they qualify for the coverage.

"And that's what fundamentally led us to the belief that rather than layer on more patches on this system, the way to ensure that everyone has basic coverage is to provide everyone with good coverage," she said.

Change of view
Finkelstein said her book notes that because of the way the U.S. health care system is set up and the nation's aversion to letting people die in the streets, no one is completely without some access to care. The uninsured still get medical care, she said, they just pay for about one-fifth of the cost with the rest picked up by public funding.

For decades, Finkelstein said, health economists such as herself have argued that people should have to pay at least part of the cost of their medical care so that they don't overwhelm the system with demands for care. She now believes that position was wrong because across the globe, whenever co-pays have been instituted, so have layers of exemptions and exceptions.

"So they basically created the mess we have in the United States, albeit at the small level of cost sharing, and not actually saved any money," she said.

Finkelstein said the United States spends about 18% of its economic output on health care. The average for other high-income countries, where universal care is standard, is about 9%. However, she said, U.S. costs are about evenly split between public and private funds, so U.S. taxpayers are spending 9% of the nation's economic output on health care.

"Our tax dollars are already paying for universal basic coverage," she said. "We're just not getting it."

Hoping to inspire
Finkelstein said her and her co-author's proposal is, in essence, to flatten out the public spending to provide free "basic automatic universal care." People with means could continue to spend their own money on care upgrades such as choosing their doctors and getting nice hospital rooms.

"I'm very excited that this organization is embracing bold change," Finkelstein told the assembly audience. "I think it's high time and long overdue in U.S. health care and I hope these ideas have inspired or excited some of you."

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